Psychotherapy and Older Adults Resource Guide

Introduction

Since about 1990, changes in the Medicare reimbursement system have allowed psychologists to provide services to older adults with Medicare coverage. These changes, in combination with managed care and market place changes have made older adult clients attractive as a client population to increasing numbers of psychologists and other mental health service providers. As the Baby Boomers become older adults over the next several years, one can expect both the need and the demand for mental health services to increase: Need is likely to change because Boomers have higher prevalence of depression and other mental disorders than do the GI Generation and Depression era cohorts; Demand may change because Boomers have typically been psychologically minded and relatively high consumers of mental health services.

Key questions in thinking about working with older adults concern whether psychological interventions can be expected to work with older adults. If they work, are adaptations from work with younger adults necessary? In this resource page, research bearing on both of these questions is summarized.

Does therapy work with older adults?

Before turning to psychological interventions, which are the main focus of this resource guide, it should be noted that psychological assessment with older adults is more specialized than are interventions. The higher prevalence of the dementias in late life make some level of neuropsychological screening essential. The higher prevalence of medical disorders makes attention to physical causes of symptoms and to iatrogenic effects of medications as causes of symptoms highly important as well. For more on geropsychological assessment see Lichtenberg (1999).

Gatz et al. (1998) reported that behavioral and environmental interventions for older adults with dementia met the standards proposed at that time for well-established empirically supported therapy. Probably efficacious therapies for the older adult included cognitive behavioral treatment of sleep disorders and psychodynamic, cognitive, and behavioral treatments for clinical depression. For nonsyndromal problems of aging, memory retraining and cognitive training are probably efficacious in slowing cognitive decline. Life review and reminiscence are probably efficacious in improvement of depressive symptoms or in producing higher life satisfaction. Scogin & McElreath (1994) reported a meta-analysis of psychological interventions for the treatment of depression in later life which showed an aggregate effect size (d = .78) roughly equal to that found in another meta-analysis for anti-depressant medications (d = .57, Schneider, 1994) and roughly equal to that found for younger adults in meta-analyses using cognitive-behavioral approaches (d = .73; Robinson, Berman, & Neimeyer, 1990; some studies overlap with those used in Scogin & McElreath, 1994). In general, then, available evidence supports the effectiveness of psychological interventions with older adults, for those interventions that have been studied.

Does therapy change when working with older clients?

Drawing upon life span developmental psychology, social gerontology, and clinical experience I have developed a transtheoretical framework for thinking about what changes are needed in psychological interventions with older adults: the contextual, cohort-based, maturity, specific challenge model (CCMSC; Knight, 1996). CCMSC is not a specific therapy system but a framework for thinking about the adaptation of any therapy system to work with older adults. In the model, context means that changes in therapy are often related to the social-environmental context of older adults both in the community and more especially within hospital and nursing home settings, rather than to their developmental stage. Cohort differences are based on maturing in a specific historical time period, leading to a focus on generational groups such as Depression-era generation, GI Generation, Baby Boomers, rather than on age groups. Developmental maturation leads to relatively minor changes, such as slowing down and the use of simpler language, but also to greater emotional complexity and a wealth of life experience upon which to draw. Specific challenges means that due to the high prevalence of chronic medical problems and neurological disorders, a higher percentage of psychological assessment and therapy is related to medical problems these problems. There is also a higher frequency of grief work and of attention to caregiving issues.

In short, the answer to the question of whether psychotherapy needs to be adapted for work with older adults is, Yes, but (mostly) NOT because they are older. That is, the major reasons for changing therapy when working with an older client are not due to developmental differences but to context effects, cohort effects, and specific challenges common in later life. Context effects require changes for older clients living in age specific contexts such as retirement communities and long term care settings as well as for clients who are seen in de facto age contexts such as hospitals and outpatient medical settings. Cohort effects require modifications because earlier born cohorts have different skills, different values, and different life experiences than later born cohorts. The specific challenges of later life require specific knowledge and therapeutic skills because of the problems they pose for clients, not because of the client's age.

How specialized does a therapist need to be to work with older adults? It will likely depend on the number and type of older adults seen in the practice. Therapists who see a small percentage of older adults, who see older adults who are physically healthy and not likely to have dementia, and whose older clients have problems similar to those of their younger clients, are not likely to need specialized training or education to work with older clients.

Adapting to work with members of other cohorts is similar in difficulty and in the type of changes required to working with clients of a different gender, ethnicity, class background, or occupation-based lifestyle. It does require sensitivity to the possibility of the difference. It also requires some knowledge of history before one was born or at least the willingness to learn that history from clients.

In terms of context effects, if the work with older adults is primarily in long term care settings or in acute medical settings, the work will be specialized compared to work with healthy younger adults living and working in the community. The differences are due to the specialized environmental context rather than to the age of the clients. It is likely to be somewhat similar to working with younger adults in medical care settings and rehabilitations settings. Learning these settings is likely to require some supervised experience working in them.

While somewhat less different and therefore less specialized than the institutional settings, seeing clients who are living a post-retirement lifestyle, especially if some of their lives are spent in age-segregated environments, requires learning the social rules of those environments. Like cohort differences, these can be learned from older clients, but the therapist must be aware of the need to attend to these differences. Otherwise, judgments will be made based on the norms and folkways of young and middle-aged adults whose lives are shaped by school, work, and young families rather than by leisure time, senior community centers or meal sites, and the dispersed networks of older families.

In terms of specific challenges, if the older clients are physically ill, this will pose new issues in both assessment and also in intervention with them. Sorting out physical and psychological influences on symptoms and problems is an ongoing assessment issue. Specific knowledge about the effects of different chronic illnesses as well as both the skill and emotional readiness to work with physically disabled clients become essential. Consultation and supervised experience with psychologists who have such experience is likely to needed in addition to didactic instruction.

When working with clients with death and dying issues, the therapist needs to have basic skills in death counseling and in grief work. The primary problem I have observed over the years is therapists failing to recognize that clients need to talk about the death of loved ones sometimes even when this is the client's stated presenting problem. Learning to work effectively with death, dying, and grief is likely to require supervision as well as didactic instruction.

Working with caregivers requires some basic understanding of the stress and coping process as it affects caregivers for frail older adults. Therapy with caregivers will usually include some need to explore relationship issues and family issues as well. This work often includes a dual focus on emotional issues for the caregiver and problem solving in order to reduce the real stress and strain of long term caregiving for a seriously disabled family member.

The more of these factors that are present, the more specialized working with older adults becomes. Other things being equal, the larger the proportion of older adults in one's caseload, the more likely it is that these factors will be present, whether the therapist is immediately aware of them or not. As noted above, assessment practice with older adults requires some degree of specialized training and work in long term care or other medical settings with older adults will require specialization in learning to work effectively in that setting.

In short, seeing some older adults that are much like the other adults in one's practice does not require much specialization. Seeing a lot of older adults, seeing older adults who have different problems, or seeing them in different settings requires specialized knowledge and supervised experience.

Bob G. Knight, PhD
University of Southern California
Updated: October 2009

Journal Articles

Methodology for discovering and teaching countertransference toward elderly clients
Altschuler, J. & Katz, A.D. (1999) Journal of Gerontological Social Work, 32(2), 81-93.

Describes a method that has been effective in helping students, paraprofessional counselors as well as mental health professionals identify countertransference reactions in themselves. The author developed a sentence completion exercise that can be used to elicit and uncover countertransference responses toward elderly people. It offers instructors and clinical supervisors a way to teach about countertransference toward elderly clients. This technique can be used in a variety of work settings such as classrooms, mental health clinics, multi-purpose centers for older adults and private practice.

Effectiveness of problem-solving therapy for older, primary care patients with depression: Results from the IMPACT project
Arean, P., Hegel, M., Vannoy, S., Fan, M. Y., & Unutzer, J. (2008). The Gerontologist, 48(3), 311-323.

The study compares a primary-care-based psychotherapy, that is, problem-solving therapy for primary care (PST-PC), to community-based psychotherapy in treating late-life major depression and dysthymia. Older adults who received PST-PC had more depression-free days at both 12 and between 12 and 24 months and they had fewer depressive symptoms and better functioning at 12 months than those who received community-based psychotherapy. Results suggest that PST-PC as delivered in primary care settings is an effective method for treating late-life depression.

Assessment and Treatment of Depressed Older Adults in Primary Care
Arean, P., & Ayalon, L. (2005). Clinical Psychology: Science and Practice, 12(3), 321-335.

The purpose of this paper is to describe and discuss both assessment and psychotherapeutic techniques that can be applied in primary-care medicine for older adults seeking mental health services in these settings. Assessment techniques that are amenable to primary-care settings include the Center for Epidemiological Studies Depression Scale, Revised; the Geriatric Depression Scale-15; two and nine-symptom Patient Health Questionnaire; the General Health Questionnaire; the Beck Depression Inventory-ll; and the Beck Depression Inventory for Primary Care. Psychotherapeutic interventions that have been created and/or modified for primary-care settings are Problem solving therapy (PST-PC) and interpersonal therapy (IPT-PC). These detection tools and treatments are discussed in the context of primary-care medicine.

Evidence-based psychological treatments for late-life anxiety
Ayers, C. R., Sorrell, J. T., Thorp, S. R., & Wetherell, J. L. (2007). Psychology and Aging, 22(1), 8-17.

This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults.

A randomized trial of the effectiveness of cognitive-behavioral therapy and supportive counseling for anxiety symptoms in older adults
Barrowclough, C., King, P., Colville, J., Russell, E., Burns, A., & Tarrier, N. (2001). Journal of Consulting & Clinical Psychology, 69(5), 756-762.

The authors used a randomized trial to compare cognitive-behavioral therapy (CBT) and supportive counseling (SC) in the treatment of anxiety symptoms in older adults who met Diagnostic and Statistical Manual of Mental Disorders criteria for anxiety disorders. Both conditions had a 6-week baseline no-treatment phase. Treatment was delivered primarily in patients' own homes and in an individual format. Outcomes were assessed at post treatment and at 3-, 6-, and 12-month follow-ups. There was no spontaneous improvement during the baseline phase. Both groups showed improvement on anxiety measures following treatment, with a better outcome for the CBT group on self-rating of anxiety and depression. Over the follow-up period, the CBT group maintained improvement and had significantly greater improvement than the SC group on anxiety and 1 depression measure. Treatment response for anxiety was also superior for the CBT group, although there was no difference between groups in endstate functioning.

Presentation of depression and response to group cognitive therapy with older adults
Cappeliez, P. (2001). Journal of Clinical Geropsychology, 6(3), 165-174.

Examines the relationships between pretreatment components of depressive symptomatology and outcome of short-term group cognitive therapy for depression with older adults (aged 65+ yrs). Aspects of depressive symptomatology under examination were initial intensity of self-reported symptomatology, profile of melancholic depression, perceived health status, perceived social support, and intensity of negative view of self. Findings indicate that perceived social support is not related to outcome, but that a more intense depressive symptomatology, a more negative health evaluation, and a more negative view of self are variables associated with a less favorable outcome. Despite showing a sizable decrease in depressive symptoms over the course of intervention, severely depressed Ss still presented residual depressive symptoms at the conclusion of intervention. There was a tendency for Ss with a melancholic profile to show a poorer response to this intervention.

Cognitive-behavioral therapy with older adults
Dick-Siskin, L.P. (2002). Behavior Therapist, 25(1), 3-6.

This discussion focuses on recommendations for working with older adults receiving cognitive-behavioral therapy (CBT). The following topics are addressed: is CBT effective with older adults, what brings older adults to treatment, the intake process, introducing CBT to the older adult, threats to the collaborative relationship, sensory changes in aging, suggestions to enhance cognitive interventions, and suggestions to enhance behavioral interventions. The case of an 82-yr-old female is offered as an example of CBT with older adults.

Cognitive-behavior therapy for older adults: How does it work?
Floyd, M., & Scogin, F. (1998). Psychotherapy, 35(4), 459-463.

The basic premise of cognitive-behavior therapy (CBT) is that depression is mediated by depressogenic patterns of thinking. Research with a general adult population has not consistently supported the proposed mediational effect of depressogenic thinking (M. Whisman, 1993), as measured by the Dysfunctional Attitudes Scale (DAS) of A. T. Beck et al (1991). Research suggests that the mediational effect of the DAS is even weaker with an older adult population. Proposed reasons for this age difference include a greater effect of the "common factors" of psychotherapy (S. Ilardi and W. Craighead, 1994) and an increased need to specifically treat hopelessness in older adults.

Comparative Effects of Cognitive-Behavioral and Brief Psychodynamic Psychotherapies for Depressed Family Caregivers
Gallagher-Thompson, D., & Steffen, A.M. (1994). Journal of Consulting and Clinical Psychology, 62(3), 543-549.

Clinically depressed family caregivers of frail, elderly relatives were randomly assigned to 20 sessions of either cognitive-behavioral or brief psychodynamic individual psychotherapy. At post treatment, 71% of the caregivers were no longer clinically depressed according to research diagnostic criteria, with no differences found between the two outpatient's treatments. The results suggested therapy specificity; there was an interaction between treatment modality and length of caregiving on symptom-oriented measures. Clients who had been caregivers for at least 44 months improved with CB therapy. These findings suggest that patient-specific variables should be considered when choosing treatment for clinically depressed family caregivers.

Commentary on evidence-based psychological treatments for older adults
Gatz, M. (2007). Psychology and Aging, 22(1), 52-5.

This article comments on the articles in the Special Section on Evidence-Based Psychological Treatments for Older Adults. The articles apply criteria developed by the Society of Clinical Psychology to evaluate treatments for late-life anxiety, insomnia, behavior disturbances in dementia, and caregiver distress. The articles document that there are evidence-based psychological treatments that can help older adults. However, there are 2 substantial hurdles: evidence and access. Gaps in the evidence, as mentioned by the authors of the articles in the special section, result from disproportionate research attention to some psychotherapies and some mental disorders, with corresponding lack of research about other treatments and disorders. The challenge for access is to ensure that older adults with treatable mental disorders will get connected to psychologists trained in these evidence-based therapies.

Empirically Validated Psychological Treatments for Older Adults
Gatz, M., Fiske, A., Fox, L., Kaskie, B., Kasl-Godley, J., & McCallum, T. (1999). Journal of Mental Health and Aging, 4(1), 9-46.

Psychological treatments with older adults were evaluated against criteria developed by the Division of Clinical Psychology of the American Psychological Association for documenting effective psychosocial interventions. To be included as evidence, the studies must exclude dual or ambiguous diagnoses and must adhere to standardized treatment manuals. Demonstrated efficacy compared to waiting list control groups qualifies an intervention as "probably efficacious", whereas being categorized as "well established" requires superiority to a psychological placebo group or control treatment (or equivalence to another well-established treatment). Major findings included: use of behavioral and environmental treatments for behavior problems in dementia patients met criteria for "well established"; cognitive, behavioral, and brief psychodynamic therapy for the treatment of depression in older adults met criteria for "probably efficacious"; life review and reminiscence met the criteria for "probably efficacious" for both cognitively intact and demented individuals with symptoms of depression and those living in settings that restrict independence; cognitive behavioral treatment of sleep disorders, support groups for caregivers based on a psychoeducational model, and memory and cognitive retraining with dementia patients all met the criteria for "probably efficacious."

Time's winged chariot: Short-term psychotherapy in later life
Gorsuch, Nikki. (1998). Psychodynamic Counseling, 4(2), 191-202.

This paper is concerned with the appropriateness of short-term psychodynamic psychotherapy with older adults, a client group, which has historically been neglected in psychotherapeutic practice. Drawing on the case study of a fourteen-session therapy with a woman in her seventies, it is argued that brief exploratory work can be of particular value to people nearing the end of their lives. The nearness of death gives a special urgency and motivation to the work and time-limited therapeutic contract mirrors the reality of having only a short time left. Making psychotherapy available to older people also represents an important valuing and validation of their experience.

The management of sexualized transference and countertransference with older adult patients: Implications for practice
Hillman, J., & Stricker, G. (2001). Professional Psychology - Research & Practice, 32(3), 272-277.

For a variety of reasons, psychologists are beginning to see an increasing number of older adults in their practice. However, the sexualized transference and countertransference sometimes encountered with older adult patients can foster therapeutic impasse and resistance in treatment among both novice and experienced therapists. Societal taboos and therapy within the context of institutional settings (e.g., nursing homes) can make the management of these dynamics particularly challenging. Although difficult to broach, an analysis of sexualized dynamics can provide valuable information regarding an elderly patient's sense of intrinsic value, beliefs about power and agency, and difficulties with or desires for emotional intimacy. Case examples and implications for practice are presented.

Interpersonal psychotherapy as a treatment for depression in later life
Hinrichsen, G. A. (2008). Professional Psychology: Research and Practice, 39(3), 306-312.

Depression affects only a minority of older adults, but is a costly illness in terms of suffering, excess medical disability, increased use of health services, and mortality. Both pharmacological and psychotherapeutic interventions are effective for treating depression in late life. This paper reviews the background and empirical support for the efficacy of various psychotherapies for treating late life depression, including cognitive-behavioral, interpersonal, psychodynamic, life review, group, and family interventions. To date, cognitive-behavioral and interpersonal psychotherapies have most empirical support yet most studies have been conducted with relatively young, healthy, and White elderly. Studies of the efficacy of psychotherapeutic interventions for treating depression in minority and frail elderly are needed, as well as further studies of combination treatments across a range of care settings.

GIST: An efficient and effective cognitive behavioral therapy in long term care
Hyer, L., Hilton, N., Sacks, A., Freidman, M., & Yeager, C. (2009). American Journal of Alzheimer's Disease and other Dementias, 23(6), 528-539.

Depression is a major problem in long-term care (LTC) as is the lack of related empirically supported psychological treatments. This small study addressed a variant of cognitive behavioral therapy, GIST (group, individual, and staff therapy), against treatment as usual (TAU) in long-term care. There were significant differences between GIST and TAU in favor of GIST on the GDS-S and LSI-Z. The GIST group maintained improvements over another 14 sessions. After crossover to GIST, TAU members showed significant improvement from baseline. Participants also reported high subjective ratings of treatment satisfaction. This trial demonstrated GIST to be more effective for depression in LTC than standard treatments.

Geropsychological interventions in long-term care
Hyer, L., & Intieri, R. (2006). New York: Springer Publishing Company

Hyer and Intrieri have gathered together a group of health care professionals who are genuinely dedicated to the care and research of long-term care (LTC) environments. The editors address the challenge of LTC--ways to allow residents to thrive in an environment at the end of life. This book also provides you with ways to improve use of your professional time, effort, and input in LTC. By applying the Selective Optimization with Compensation (SOC) model to various care settings, the editors examine current LTC practices and existing psychosocial issues confronting older LTC patients. They offer suggestions and strategies, such as Cognitive Behavior Therapy, for improving the LTC system and residents' physical, psychological, emotional, and social health. This book provides you with insight on the psychological issues facing LTC residents whether you are: physicians and geriatricians who care for older adults in the LTC system; nurses and geriatric nurse specialists; social workers; activity coordinators; physical, occupational, and speech therapists within an LTC setting who are seeking ways to explain behavior and empower the residents they care for; or psychologists and psychiatrists whose practice focuses on older adults.

Psychosocial intervention for individuals with dementia: An integration of theory, therapy, and a clinical understanding of dementia
Kasl-Godley, J., & Gatz, M. (2000). Clinical Psychology Review, 20(6), 755-782.

Reviewed psychosocial interventions for people with dementia using an integrated framework that views the symptoms and behaviors of demented individuals as not solely a manifestation of the underlying disease process, but also reflect the social and environmental context as well as the demented individual's perceptions and reactions. Particular attention was given to 6 interventions: (1) psychodynamic approaches, (2) reminiscence and life review therapy, (3) support groups, (4) reality orientation (RO), (5) memory training, and (6) cognitive/behavioral approaches. Interventions are described in terms of theoretical basis, how knowledge about dementia is incorporated, techniques, and empirical support. The authors found that psychodynamic approaches appear helpful for understanding intrapsychic concerns of demented individuals. Support groups and cognitive/behavioral therapy assist early stage individuals to build coping strategies and reduce distress. Reminiscence and life review provide mild to moderate stage individuals with interpersonal connections. Behavioral approaches and memory training target specific cognitive and behavioral impairments and help to optimize remaining abilities. RO is similar but is more useful for its interpersonal functions.

Assessment and psychological treatment of depression in older adults with terminal or life-threatening illness
King, D. A., Heisel, M. J., & Lyness, J. M. (2005). Clinical Psychology: Science & Practice, 12(3), 339-353.

Depression decreases the quality of life and hinders efforts to palliate symptoms of adults with terminal or life-threatening illness. Nevertheless, depression often may go undetected and untreated in palliative care and hospice settings due to a number of factors, including the overlap of depressive symptoms with those of serious medical illness and concern that frail elderly patients cannot tolerate psychotherapy or antidepressant treatment. In this paper we review the available research regarding assessment and treatment of depression in older adults with terminal or life-threatening illness, focusing on patients who are seen in palliative care, cancer treatment, or hospice settings. Although the prevalence of depression is relatively high in these settings in mixed-age adult samples, studies focused exclusively on older adults are rare and there appear to be no randomized controlled trials of psychotherapy conducted to date that specifically address their needs. There are, however, promising psychological approaches featured in case reports and pilot studies that are consistent with empirically supported therapies for the general treatment of depression in older adults. Based on these preliminary findings and reports, we offer tentative recommendations for the assessment and treatment of depression in terminally ill older adults. We conclude that controlled research on psychotherapy for late-life depression is both feasible and urgently needed in palliative care, cancer care, and hospice settings.

The scientific basis for psychotherapeutic interventions with older adults: An overview
Knight, B.G. (1999). Journal of Clinical Psychology, 55(8), 927-934.

Findings from reviews of outcome studies indicate that therapy is effective with older adults. The contextual, cohort-based, maturity, specific-challenge model (CCMSC) is used to organize an overview of findings from scientific gerontology. These findings suggest that some adaptations are needed when working with older adults, but that these changes are more often due to cohort-differences, context effects, and presenting problems rather than to the age of the client.

Adapting psychotherapeutic practice for older clients: Implications of the contextual, cohort-based, maturity, specific challenge model
Knight, B.G., & McCallum, T.J. (1998). Professional Psychology - Research & Practice. 29(1), 15-22.

The contextual, cohort-based, maturity, specific challenge model integrates concepts from gerontology with psychotherapy to apply those ideas in psychotherapy with older adults. The model suggests that older adults display greater maturity than younger adults but may also be facing some of the most difficult challenges of adulthood. The model further asserts that the social context of older adults and the fact that they are members of earlier-born cohorts should be recognized and incorporated into the psychotherapeutic process. Although the model outlines important differences between older and younger adults in therapy, similarities often outweigh differences between the groups as the process of psychotherapy unfolds.

Older adults' acceptance of psychological and pharmacological treatments for depression
Landreville, P., Laudry, J., Baillargeon, L., Guerette, A., & Matteau, E. (2001). Journal of Gerontology: Psychological Sciences, 56B, 285-291.

Two hundred participants aged 65 and older recruited from 4 different family medicine clinics rated the acceptability of 3 different treatments for geriatric depression: (a) cognitive therapy (CT), (b) cognitive bibliotherapy (CB), and (c) antidepressant medication (AM). Results showed that the acceptability of the treatments is a function of the severity of the symptoms of the depressed patient to whom they would be applied. CT and CB were rated as more acceptable than AM when patient symptoms were mild to moderate. However, CT was more acceptable than both CB and AM when patient symptoms were described as severe. Acceptability ratings were not related to the raters' own depressive symptoms. The practical implications of these results are discussed.

Psychological assessment and psychotherapy in long-term care
Lichtenberg, P.A., & Duffy, M. (2000). Clinical Psychology-Science & Practice, 7(3), 317-328.

The continued growth of the older adult population, combined with the inclusion of psychologists in Medicare, is leading to psychological services increasingly being delivered in long-term care settings. This article reviews some basic concepts in psychological assessment and psychotherapy with older adults in long-term care settings. A guide is provided for the assessment of dementia, delirium, and depression. The use of validated empirical instruments, the collection of multiple sources of historical data, and the incorporation of assessment results in treatment planning is emphasized. Psychotherapy with persons having a dementia and psychotherapy with persons having a personality disorder is the focus of the treatment section of this article. The authors argue that these have been neglected areas of practice, and yet treatment can produce significant benefits to these patients. A general approach to assessment and a guide for integrating the assessment results into the plan of care are outlined.

Evidence-based psychotherapeutic interventions for geriatric depression
Macklin, R., & Arean, P. (2005). Psychiatric Clinics of North America, 28, 805-820.

This review systematically evaluates the evidence base for psychotherapy as an empirically supported treatment of late-life depression and is an update of the present authors' recent review of the literature.

How effective are psychotherapeutic and other psychosocial interventions with older adults? A meta analysis
Pinquart, M. & Soerensen, S. (2001). Journal of Mental Health and Aging, 7(2), 207-243.

Meta-analysis was used to synthesize the effects of 122 psychosocial and psychotherapeutic intervention studies with older adults. Three research questions were explored: (1) what is the effectiveness of psychotherapeutic and psychosocial treatments (cognitive-behavioral therapy, reminiscence, psychodynamic approaches, relaxation, supportive interventions, control enhancement, psychoeducational treatments, activity treatments and training of cognitive abilities) on self-ratings of depression, clinician-rated depression, and other measures of subjective well-being in older adults; (2) the influences of moderator variables, and (3) whether the effects of psychosocial and psychotherapeutic interventions vary by age. Psychotherapeutic interventions changed self-rated depression and other measures of psychological well-being by about one half standard deviation and clinician-rated depression by more than one standard deviation.

Psychotherapy in long-term care: I. Practical considerations and the link to policy and advocacy
Powers, D. V. (2008). Professional Psychology: Research and Practice, 39(3), 257-263.

Psychotherapy in long-term care: By Powers, David V.
Professional Psychology: Research and Practice. Vol 39(3), Jun 2008, 251-256.
This article is the 1st of 2 examining 3 domains that are important to providing high-quality, evidence-based services to long-term care (LTC) residents: policy and advocacy, practical considerations, and outcome research. Older adults who reside in LTC facilities have a very high rate of mental health difficulties. Psychologists have been able to provide services to this population through Medicare since the late 1980s, resulting in an increase in psychologists who are working with LTC residents, either as part of their practice or on a full-time basis. The focus of this article is on practical considerations for therapists in LTC settings from both the published literature and personal observations (including an illustrative case example), the current policy environment, and the importance of advocacy on behalf of clients.

Psychotherapy in long-term care: II. Evidence-based psychological treatments and other outcome research
Powers, D. V. (2008). Professional Psychology: Research and Practice, 39(3), 257-263.

This article is the 2nd of 2 that together examine 3 domains important to providing high-quality; evidence-based services to long-term care (LTC) facility residents: policy and advocacy, practical considerations, and outcome research. Older adults who reside in LTC facilities have a very high rate of mental health difficulties. Psychologists have been able to provide services to this population through Medicare since the late 1980s, and empirical findings on treatment approaches are important in guiding psychotherapists to more helpful intervention. The focus of this article is outcome research in LTC settings. This article emphasizes evidence-based psychological treatments (EBTs) but also examines other scientifically supported approaches and discusses the strengths and limitations of focusing on EBTs, as well as general issues in the relation between science and practice in the provision of psychotherapy in LTC settings.

Cognitive-behavioral interventions with older adults: Integrating clinical and gerontological research
Satre, D., Knight, B., & David, S. (2006). Professional Psychology: Research and Practice, 37(5), 489-498.

Psychotherapeutic interventions utilizing cognitive-behavioral strategies have been used widely with older adults. To appropriately adapt these techniques, characteristics unique to older adults must be taken into account. These factors include aspects of the social environment, cohort effects, cognitive changes with aging, personality, and emotional development, which have been described in an emerging body of research literature from the field of gerontology. In addition, clinical studies have examined the efficacy of cognitive-behavioral interventions in treating older clients for anxiety, depression, insomnia, and other disorders. This review describes current empirical evidence in gerontology and treatment outcome research that informs the practice of psychotherapy in this population and provides recommendations for conducting therapy with older adults.

Evidence-based psychotherapies for depression in older adults
Scogin, F., Welsh, D., Hanson, A., Stump, J., & Coates, A. (2005). Clinical Psychology: Science and Practice, 12(3), 222-237.

A practical resource created by a team of international luminaries in the field. Developed in conjunction with the Gerontology Center of the University of Colorado, this expert guide provides evidence-based treatment approaches for alleviating depression in older adults.

Diagnosis and assessment of personality disorders in older adults: A critical review
Segal, D., Hersen, M., Van Hasselt, V., Silberman, C., & et al. (2006). Journal of Personality Disorders, 10(4), 384-399.

Reviews diagnostic and assessment approaches for personality disorders in older adults. The belief that character pathology either is not present or is not a serious difficultly in older individuals and the limited relevance or applicability to aged clients of the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for personality disorders are 2 factors that complicate diagnosis and assessment of personality disorders in older adults. Assessment of older adults using the MMPI, Millon Clinical Multiaxial Inventory (MCMI), and the Coolidge Axis II Inventory is outlined and comparisons are made.

Efficacy of psychosocial treatments for geriatric depression: A quantitative review
Scogin, F. & McElreath, L. (1994). Journal of Consulting and Clinical Psychology, 62(1) 69-74.

A meta-analysis of 17 studies examined the efficacy of psychosocial treatments for depression among older adults. Psychosocial treatment was defined as an intervention, the primary mode of action which was through psychological or social mechanisms such as psychotherapy, bibliotherapy, or behavior therapy. Studies were included only if a comparison was made to a control condition (no treatment, delayed treatment, or placebo treatment) or another psychosocial intervention. Results indicated that treatments were reliably more effective than no treatment on self-rated and clinician-rated measures of depression. Effect sizes for studies involving participants with major depression disorder were also reliably different from zero, as were effect sizes from studies involving participants with less severe levels of depression. These findings compare favorably with several other quantitative reviews of treatments for depression. Results suggest more balanced presentations of the potential benefits of psychosocial interventions are warranted.

Residual geriatric depression symptoms: A place for psychotherapy
Scogin, F., Shackelford, J., Rohen, N., Stump, J., Floyd, M., McKendree-Smith, N., & Jamison, C. (2001). Journal of Clinical Geropsychology, 7(4), 271-283.

Geriatric depression is a relatively commonly occurring mental disorder. A subpopulation of depressed older adults are those who have engaged in or completed pharmacotherapy, yet continue to experience depressive symptoms. The authors review the prevalence, psychosocial effects, and treatment of residual symptoms of depression in older adults. Data from previous studies conducted by our group are presented to support our contention that residual symptoms of geriatric depression are treatable through psychosocial means.

Introduction to the special section on evidence-based psychological treatments
Scogin, F. (2007). Psychology and Aging, 22(1), 1-3.

The methods used to identify evidence-based psychological treatments for older adults are described. A review of the procedures followed to identify specific psychological treatments with the help of the manual developed by the Committee on Science and Practice of the Society for Clinical Psychology of the American Psychological Association is provided.

Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: A randomized clinical trial
Stanley, M. A., Wilson, N. L., Novy, D. M., Rhoades, H. M., Wagener, P. D., Greisinger, A. J., & et al. (2009). The journal of the American Medical Association, 301(14), 1460-1467.

Cognitive behavior therapy (CBT) can be effective for late-life generalized anxiety disorder (GAD), but only pilot studies have been conducted in primary care, where older adults most often seek treatment. The study examines effects of CBT relative to enhanced usual care (EUC) in older adults with GAD in primary care.

Treatment of generalized anxiety in older adults: A preliminary comparison of cognitive-behavioral and supportive approaches
Stanley, M.A., Beck, J.G., & Glassco, J.D. (1996). Behavior Therapy, 27(4), 565-581.

Compared the efficacy of cognitive behavior therapy vs. nondirective, supportive psychotherapy for 31 older adults (aged 55+ yrs) with well-diagnosed Generalized Anxiety Disorder (GAD). Treatments were administered in small groups that met for 14 weekly half-hour sessions. Treatment effects were assessed at post treatment and over a 6-mo follow-up period. Two composite indexes of treatment response were derived to identify treatment responder status and high end-state functioning. Results show significant improvements on outcome variables measuring worry, anxiety, and depression in both treatment conditions. Effect sizes generally were large, and treatment gains were maintained or improved over the 6-mo follow-up phase. Examination of treatment responder status and end-state functioning revealed no significant differences between groups.

Behavioral treatment of depression in dementia patients: A controlled clinical trial
Teri, L. (1997). Journals of Gerontology Series B-Psychological Sciences & Social Sciences, 52B(4), 159-166.

The current study is a controlled clinical investigation of 2 nonpharmacological treatments of depression in patients with Alzheimer's disease (AD). Two active behavioral treatments, one emphasizing patient pleasant events and one emphasizing caregiver problem solving, were compared to an equal-duration typical care condition and a wait list control. 72 patient-caregiver dyads were randomly assigned to 1 of 4 conditions and assessed pre- and post-treatment, and at 6-mo follow-up. Patients in both behavioral treatment conditions showed significant improvement in depression symptoms and diagnosis as compared with the 2 other conditions. These gains were maintained at follow-up. Caregivers in each behavioral condition also showed significant improvement in their own depressive symptoms, while caregivers in the 2 other conditions did not. Results indicate the importance and effectiveness of behavioral interventions for treatment of depression in AD patients and their caregivers.

Psychosocial treatment of depression in older adults with dementia
Teri, L., McKenzie, G., & LaFazia, D. (2005). Clinical Psychology: Science & Practice, 12(3), 303-316.

Depression and dementia commonly coexist and are associated with higher rates of behavioral and functional problems. Caregivers of these individuals report higher levels of physical and mental distress, as well. Effective treatment, therefore, has the potential to help both the older adult and their caregiver. This article provides an overview of the current literature on treatment of depression in demented older adults, with particular emphasis on providing guidelines for evidence-based clinical care. Eleven randomized controlled clinical trials were identified following an extensive review of the literature. These studies are reviewed with particular attention to the methodological issues of most relevance to clinicians attempting to use the findings from these studies to guide their practice. Issues of particular relevance when working with this population are also addressed, including (a) for assessment-differential and coexistent diagnosis of depression in dementia, use of collateral informants, self-report and interviewer-obtained information; and b) for treatment-the need for caregiver involvement, individualizing of goals, and planning for future deterioration of cognitive function.

Comparison of desipramine and cognitive/behavioral therapy in the treatment of elderly outpatients with mild-to-moderate depression
Thompson, L., Coon, D.W., Gallagher-Thompson, D., Sommer, B.R., & Koin, D. (2001). American Journal of Geriatric Psychiatry, 9(3) 225-240.

This study evaluated the efficacy of desipramine alone vs. cognitive/behavioral therapy alone (CBT) vs. a combination of the two, for the treatment of depression in older adult outpatients. 102 patients (mean age 66.8 yrs) meeting criteria for major depressive disorder were randomly assigned to one of the three treatments for 16-20 therapy sessions. All treatments resulted in substantial improvement. In general, the CBT only and combined groups had similar levels of improvement. In most analyses, the combined group showed greater improvement than the desipramine alone group, whereas the CBT alone group showed only marginally better improvement. The combined therapies were most effective in patients who were more severely depressed, particularly when desipramine was at or above recommended stable dosage levels.

Cognitive behavioral psychotherapy: A comparison between younger and older adults in two inner city mental health teams
Walker, D.A., & Clarke, M. (2001). Aging & Mental Health, 5(2), 197-199.

To assess the feasibility of establishing a new cognitive behavior therapy (CBT) service specifically for older adults (aged 66-80 yrs), the authors decided to compare an older adult mental health service with a younger adult service in terms of range of referrals, outcomes, attendance rates and length of time in therapy. Assessments were conducted using a behavioral interview. 23 older adults (aged 66-80 yrs) were referred. The range of disorders referred was a wide mix of anxiety disorders and depression. There were no significant differences in therapy outcomes apart from home adjustment measures where older adults showed greater improvement. Younger adults showed significantly higher rates of non-attendance and had higher dropout rates. Possible reasons for this are discussed. CBT appeared effective in both age groups, however older adults were treated more quickly due to a higher attendance rate.

Psychological interventions for late-life anxiety: A review and early lessons from the CALM study
Wetherell, J. L., Sorrell, J. T., Thorp, S. R., & Patterson, T. L. (2005). Journal of Geriatric Psychiatry and Neurology, 18, 72-82.

The authors review the literature on psychological treatment for anxiety in older adults, focusing on randomized, controlled trials. Evidence exists for the efficacy of relaxation training for subjective anxiety symptoms and cognitive-behavioral therapy for generalized anxiety disorder and miscellaneous anxiety syndromes, including panic disorder. The authors also present the rationale for the CALM Study (Controlling Anxiety in Later-life Medical Patients), an ongoing randomized trial in which a modular psychotherapeutic intervention for anxiety in older primary care patients is compared with treatment as usual. Data are presented from 2 pilot patients in the CALM Study, and preliminary lessons are discussed.

Overcoming obstacles in providing mental health treatment to older adults: Getting in the door
Yang, Janet A., & Jackson, C.L. (1998). Psychotherapy, 35(4), 498-505.

Older adults significantly underutilize mental health services relative to their numbers in the population. Barriers that impede their access include physical, financial, cognitive, emotional, and attitudinal issues. This article discuss strategies for overcoming these barriers including physical adaptations such as in-home psychotherapy and telephone sessions, use of support groups, strong community outreach, and liaisons with other professionals. Adaptations that help to increase older adults' use of mental health services are discussed, including education about treatment, nontraditional "pursuit" of clients, and use of alternative terminology. Informed consent is discussed as a special issue.

Books

Handbook of counseling and psychotherapy with older adults
Duffy, M. (Ed.), (1999). New York: John Wiley & Sons, Inc.

This handbook provides a much-needed resource in treatment approaches for mental health professionals who provide counseling and psychotherapy to older clients. Part I focuses on a series of treatment modalities, including the use of psychotherapy process, group and expressive approaches, family and intergenerational interventions, and social and community interventions. Part II provides conceptual and best practice interventions for a series of specific problems. This volume will be useful to a variety of interested persons, including experienced geropsychologists and geropsychiatrists, geropsychiatric nurses and social workers, and counselors who focus on mental health and aging. It will also be an important resource for experienced general therapists who wish to develop greater proficiency in working with older adults.

Innovative behavioral healthcare for older adults: A guidebook for changing times
Hartman-Stein, P.E. (Ed.) (1998). San Francisco: Jossey-Bass, Inc.

This book makes a case for the cost-cutting advantages of offering mental health programs to the fastest-growing segment of our population. The authors outline clinical and political guidelines for organizing and delivering behavioral healthcare to older adults. They present the most current research, techniques, and model programs for cost-effective and quality assessment and psychotherapy. The book also describes innovative roles and services that offer creative opportunities for clinicians.

Interpersonal psychotherapy for depressed older adults
Hinrichsen, G. A., & Clougherty, K. F. (2006). Washington, DC, US, American Psychological Association.

This volume applies interpersonal psychotherapy (IPT), as developed by Gerald Klerman, Myrna Weissman, and their colleagues, to older adults with depression. It also draws on IPT research on late-life depression conducted by Ellen Frank, Charles Reynolds, and their collaborators at the University of Pittsburgh. With cognizance of broader issues that apply to psychotherapeutic work with older adults, the original IPT framework for the treatment of depression in younger adults can be applied to older adults. The volume first reviews relevant gerontology issues that provide the broader context in which older lives are lived. Knowledge of depression and later life are then discussed in Chapter 2 along with general clinical recommendations for the assessment and treatment of older adults. In Chapter 3, we make a clinical and research case for why IPT is especially well-suited for older people. In Chapter 4, the general structure of IPT is reviewed along with a distillation of salient research. In much of the remainder of the book we discuss how to conduct IPT, drawing on our clinical experience with older people. A chapter is devoted to common problems that arise for those who are learning IPT. The final chapter includes a summary of concluding remarks and guidance for those who want to gain further knowledge and experience in the application of IPT. The book concludes with an annotated list of resources.

Assessing and treating late-life depression: A casebook and resource guide
Karel, M.J., Ogland-Hand, S., Gatz, M., & Unuetzer, J. (2002). New York: Basic Books, Inc.

This practice-oriented, research-based casebook draws on extensive clinical and academic data on late-life depression and its treatment as a resource for practitioners and researchers. The authors--a practicing psychologist and two clinical geropsychologists among them--provide an interdisciplinary framework for understanding and treating late-life depressive symptoms. The authors elucidate the problems and principles of late-life depression with fourteen extended case studies. Explicating the range of syndromes and strategies for assessing and treating them, they conclude with a guide to medications, screening tools, innovative models, and supplementary resources.

Psychotherapy with older adults (3rd ed.)
Knight, B.G. (2004). Thousand Oaks, CA: Sage Publications.

Provides a practical account of the knowledge, technique, and skills necessary to work with older adults in a therapeutic relationship. This volume considers the essentials of gerontology as well as the nature of therapy, including special content areas and common themes. It presents a comprehensive discussion of assessment and options for intervention. Numerous case examples illustrate the dynamics of the therapeutic task and issues covered in therapy and stress the human element in working with older adults

Psychotherapy for Depression in Older Adults
Knight, B. G., & Qualls, S. H. (2006). Wiley, John & Sons, Incorporated.

The first book in the new Wiley Series on Geropsychology, Psychotherapy for Depression in Older Adults is a practical resource created by a team of international luminaries in the field. Developed in conjunction with the Gerontology Center of the University of Colorado, this expert guide provides evidence-based treatment approaches for alleviating depression in older adults.

On Death and Dying
Kubler-Ross, E. (1993). New York: Macmillian.

A classic work on working with dying people and the need for professionals to be comfortable discussing death. Moving case material, sensitively presented.

Handbook of emotional disorders in later life: Assessment and treatment.
Laidlaw, K., & Knight, B. (Eds). (2008). New York, NY, US: Oxford University Press

Although perceptions and realities of ageing have changed markedly over the last few decades, it is clear to practitioners working with older people that emotional problems remain a major factor affecting health and happiness in later life. Handbook of Emotional Disorders in Later Life: Assessment and Treatment provides a concise, authoritative, and up-to-date guide to best practice in therapy with older people, for a wide range of mental health professionals. The editors bring together chapters by experienced trainers and clinicians that cover all the significant problems and issues in the assessment and treatment of emotional disorders in later life. The introductory chapters examine the individual, social, cultural, and physical experience of ageing, and provide an essential background for a caring and professional understanding of related emotional disorders and their effective treatment. Throughout the book, key research and clinical experience is reported as underlying evidence-based treatment, but the emphasis is on practical guidance for assessment and interventions, rather than detailed discussion of methodological issues. A range of expertise is provided, making this book an invaluable resource for anyone dealing with the mental health needs of older people. This book will be essential for all those working with older people, including mental health professionals such as clinical psychologists, psychiatrists, nurses, occupational therapists, counselors, service managers, and social workers.

Professional psychology in long term care: A comprehensive guide.
Molinari, V. (Ed.), (2000). New York: Hatherleigh Press.

This book provides therapists with the tools and skill sets they will need to face the challenges of administering optimal care to this growing population. The book is divided into three major sections: Assessment of Psychopathology, Treatment (including individual, family and group therapies, behavioral interventions for patients with dementia and counseling elderly dying patients), and Professional Issues such as training, private/group practice, ethics, clinical research and public policy related to the delivery of mental health care to older adults

Psychology and the aging revolution: How we adapt to longer life
Qualls, S.H., & Abeles, N. (Eds.), (2000). Washington, DC: American Psychological Association.

Examines the latest theories and research on how aging affects cognition, memory, social relationships, emotion, physical and mental health, and responses to psychotherapy. The findings presented show that although later life brings inevitable decline and losses, aging also fosters positive characteristics such as wisdom, emotional maturity, and the ability to engage in proactive strategies for shaping one's life in meaningful ways. Sections include: neuropsychology and cognitive aging, memory, emotion, social relationships in later life, health psychology, aging research and health, depression, and psychotherapy.

Changes in Decision-Making Capacity in Older Adults: Assessment and Intervention
Qualls, S. H., & Smyer, M. A. (Eds.). (2007). Wiley, John & Sons, Incorporated

Part of the Wiley Series in Clinical Geropsychology, Changes in Decision-Making Capacity in Older Adults: Assessment and Intervention helps to familiarize you with the legal and social contexts for decision making in potentially impaired individuals. Editors Sara Qualls and Michael Smyer have brought together a notable team of international contributors to provide you with a unique framework of the legal, social, and psychological approaches to assessing the ability of older adults to make decisions.

Aging Families and Caregiving
Qualls, S. H., & Zarit, S. H. (Eds.). (2009). Wiley, John & Sons, Incorporated

With the field of geriatric mental health growing rapidly in the next decade as the Baby Boomers age, this timely guide brings together a notable team of international contributors to provide guidance for caregivers, families, and those who counsel them on managing caregiving challenges for aging family members. Aging Families and Caregiving helps mental health professionals guide families and other caregivers as they adjust to the demands of caring for aging family members and provides essential guidelines for the professionals treating this special-needs population.

Personality Disorders in Older Adults: Emerging Issues in Diagnosis and Treatment
Rosowsky, E. (Ed), Abrams, R. C. (Ed), & Zweig, R. A. (Ed) (1999). Mahwah, NJ, US, Lawrence Erlbaum Associates Publishers.

This book focuses on the prevalence of personality disorders in older people and the pivotal roles they play in the onset, diagnosis, course and treatment outcomes of other emotional and cognitive problems and physical problems as well. The various authors use many different theoretical perspectives (intrapsychic, interpersonal, neuropsychological, and systems), summarize the empirical literature, present phenomenological case reports, and review psychodynamic, cognitive-behavioral, and pharmacological treatment approaches.

The first session with seniors: A step-by-step guide
Scogin, F. (2000). New Jersey: John Wiley & Sons, Inc.

This book offers practical, concrete advice for psychologists, psychiatrists, social workers, counselors, and psychiatric nurses who work with older adults. Step-by-step, the book reveals how clinicians can structure the first-and often the only-fifty-minute session to meet the special psychological needs of older adult clients. Placing particular emphasis on the skills needed to recognize the often hidden problems of senior clients, this important resource offers behavioral health care professionals clear-cut suggestions for the quick, informal evaluation of both the cognitive and medical condition of older adults.

Books on Psychotherapy and Older Adults

Book Chapters

Treating generalized anxiety in a community setting
Beck, J. G. (2008). In D. Gallagher-Thompson, A. M. Steffen, & L. W. Thompson (Eds.), Handbook of behavioral and cognitive therapies with older adults (pp.18-23). New York: Springer.

Despite the fact that older adults are more prevalent than ever before in history, our knowledge about mental health disorders in this segment of the population is surprisingly thin. Anxiety disorders are a case in point. This chapter begins by reviewing what current research indicates with respect to the symptom profile of generalized anxiety among community elders, with particular reference to the interrelationship between anxiety and depression. An overview of available assessment strategies will be included, with emphasis on the importance of conceptualizing the patient's problem using a functional analysis, in order to understand the interplay between specific symptoms in the context of the older adult's life circumstances. Current information about treating generalized anxiety in community-dwelling elders will be reviewed, to pinpoint potentially useful treatment avenues. Although significant strides towards understanding how to treat generalized anxiety in older adults have been made, the empirical literature does not yet point to specific treatments that have established support for obtaining good outcomes. As such, the practitioner needs to be mindful in constructing treatment so as to maximize potential benefits, which may result in treatment models that involve considerable individualization. In many respects, it is an exciting era to work clinically with older adults, as the potential for discovery and innovation is high.

Psychotherapy with older adults: Theoretical issues, empirical findings, and clinical applications
Bortz, J.J., & O'Brien, K.P. (1997). In P.D. Nussbaum, (Ed.), Handbook of neuropsychology and aging. Critical issues in neuropsychology (pp. 431-451). New York: Plenum Press.

An overview of key issues relevant to psychotherapy with older adults, including accessibility and utilization of mental health services and relevant clinical, empirical, and theoretical issues in the diagnostic categories of late-life depression, anxiety, obsessive-compulsive disorder, alcoholism and substance abuse. Concludes with a discussion of suggested guidelines for therapeutic interventions with both cognitively intact and impaired older adults, with particular attention to psychiatric disability in individuals with neurological disorders.

Assessment and treatment of anxiety in later life
Cully, J. A., & Stanley, M. A. (2008). In K. Laidlaw & B. Knight (Eds.), Handbook of emotional disorders in later life: Assessment and treatment (pp.233-256). Oxford: Oxford University Press.

Anxiety symptoms and disorders in late life are associated with a number of negative consequences, including decreased physical activity and functional status, poor self-perceptions of health, decreased life satisfaction, and increased loneliness, even with adjustments for demographic factors and medical illness. Anxiety of older people also is associated with increased physical disability, decreased quality of life, and increased service use. Rates of coexistent depressive disorders are high, and anxiety has been associated with increased mortality and risk of coronary artery disease in men. Despite the high prevalence, anxiety in older adults is commonly not recognized and is inappropriately treated, due to a variety of factors, including the complexity of diagnosing anxiety in older adults, as well as practitioner- and system-related barriers (e.g., time, knowledge, resources). This chapter addresses the importance and complexity of diagnosing and treating late-life anxiety disorders, with a particular emphasis on practical clinical applications. Treatment includes both psychotherapeutic techniques and pharmacotherapy interventions.

Psychotherapy with older people
Culverwell, A., & Martin, Carol. (2000). In G. Corley, (Ed.), Older people and their needs: A multi-disciplinary perspective (pp. 92-106). London, England: Whurr Publishers, Ltd.

Addresses the issues relevant to therapy with older people with the aim that it would prove useful not only for those readers who are involved in the provision of psychological services but also for those who are interested in the challenges and concerns faced by older people. There is a burgeoning literature covering the use and effectiveness of a range of therapeutic approaches with older people. The chapter explores the different psychoanalytical models, which are useful for considering the experience of older people, whose lives are increasingly permeated by an awareness of mortality, necessity and limitation. Aims of therapeutic work with older people and the difficulties for therapists who work with this group are addressed. Age and interpersonal issues are explored to show there importance in the psychotherapeutic relationship with older people. The role of families, institutions and services are also explored.

Bibliography of Research and Clinical Perspectives on LGBT Aging
David, S. (2006). In D. Kimmel, T. Rose, S. David (Eds), Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives (pp. 289-307). New York, NY: Columbia University Press

This Lesbian Gay Bisexual Transgendered (LGBT) aging bibliography was compiled from multiple sources including databases, search engines, and a variety of individuals and organizations that offered references and revisions. This bibliography is intended to be a complete list of the LGBT aging literature; however, it is likely that references inadvertently have been left out. This bibliography will be updated and posted on the American Psychological Association Division 44 Website through the Division 44 Task Force on Aging. Feedback is welcome and should be directed to the Division 44 Task Force on Aging. Tina Rose has provided some updates.

Psychotherapy with older adults
Gallagher-Thompson, D., McKibbin, C., Koonce-Volwiler, D., Menendez, A., Stewart, D., & Thompson, L.W. (2000). In C.R. Snyder & R.E. Ingram, (Eds). Handbook of psychological change: Psychotherapy processes & practices for the 21st century (pp. 614-637). New York: John Wiley & Sons, Inc.

The purpose of this chapter is to review what is currently understood about effective mental health care for older adults. Specifically, the authors review patterns of mental health access Issues pertaining to assessment of older adults presenting with physical and psychological symptomatology, preparation of older adults for psychotherapy (including barriers to treatment access or engagement), efficacy of different forms or models of psychotherapy with older adults, and limitations of the authors current knowledge so that future clinicians and researchers may begin to address these gaps and ultimately enhance quality of care for the coming wave of older Americans.

Cognitive Behavior Therapy with Older Adults.
Laidlaw, K. (2006). In S. Qualls, B. Knight, (Eds), Psychotherapy for depression in older adults. Wiley series in clinical geropsychology (pp. 83-109). Hoboken, NJ: John Wiley & Sons Inc

Cognitive behavior therapy (CBT) is recognized as a well-established, empirically validated treatment for depression and anxiety, with recent research suggesting that it may be more effective at preventing relapse in depression than antidepressant medication. The primary mode of effectiveness in CBT is driven by the identification and modification of dysfunctional thoughts, beliefs, and actions, where symptom amelioration occurs through cognitive restructuring and behavioral change. Cognitive behavior therapy can be differentiated from other forms of psychotherapy by its emphasis on the empirical investigation of the patient's thoughts, appraisals, inferences, and assumptions. In CBT, the meanings patients ascribe to their experiences are the data with which therapists work. Since the early 1980s, CBT researchers have provided evidence for the utility of this approach as a treatment for late life depression. Although the literature base is still rather small with regard to the empirical evaluation of psychotherapy with depressed elders, the chapter contends that CBT for late life depression is an efficacious treatment and a much needed addition and alternative to physical treatments for depressed elders. The author notes that CBT with older people is often thought to require conceptual, procedural, and technological (in the form of interventions) adaptations to render it applicable for use with older people. This is a misconception, as shown by the fact that randomised controlled trials of standard CBT with older people record outcomes similar to those of younger adults. The application of CBT with older people leaves the therapist with the same challenges as those faced by any other psychotherapist working with older people: of applying psychology in the face of often long-term problems, problems of physical health comorbidity, and realistic and challenging life transitions. The collaborative stance of CBT is particularly helpful when working with older people because it encourages respect for the life-years' experience of the individual.

Depression in later life: Epidemiology, assessment, impact, and treatment
Powers, D. V, Thompson, L., Futterman, A., Gallagher-Thompson, D. (2002). In Gotlib, I.H. & Hammen, C.L. (Eds.). Handbook of depression (pp. 560-580). New York: Guilford Press.

The goal of this chapter is twofold: (1) to reinforce the importance of the diverse nature of depression in older adults and (2) to review key advances in research on the epidemiology, assessment, impact, and treatment of late-life depression. A review of the current literature has led the authors to focus on 5 questions that are important for both researchers and clinicians: (1) How big is the issue of late-life depression? (2) Is depression the same for older adults as for younger adults? (3) How is depression assessed? (4) What is the health impact of depression? and (5) How is depression treated and how well do the treatments work?

Family therapy with aging families
Qualls, S. H. (1996). In Zarit, S.H. & Knight, B.G. (Eds.), A guide to psychotherapy and aging: Effective clinical interventions in a life-stage context (pp. 121-137). Washington: American Psychological Association.

Family therapy addresses the mental disorders and behavior problems of older adults within their primary interpersonal context, the family / provide a rationale for conducting family therapy with later-life families, examine the history of family therapy with later-life families, suggest benefits and disadvantages of this particular therapeutic approach, and describe the theory and basic techniques used in family therapy with aging families.

Videos

Adapting Psychotherapy for Working with Older Adults - with Bob G. Knight, PhD

Dr. Knight demonstrates his approach to adjusting therapy for working with this growing population. Most adaptations to therapy with older clients involve the nature of presenting problems typically brought in by older adults and the therapist-client relationship. Older adults face problems such as chronic illness, grief, and cognitive impairment at a much higher rate than younger clients. In addition, age differences between client and therapist and generational differences in acceptance of seeking help call for the need to make adaptations in approach.
In this session, Dr. Knight works with a woman in her 80s who suffered abuse throughout her life, first at the hands of her father as a child, and later, in her marriage to a verbally and emotionally abusive husband. Dr. Knight listens to the client as she recounts her life and together they gain insight into the emotional crux of her low self-esteem.

Interpersonal Psychotherapy for Older Adults with Depression - with Gregory A. Hinrichsen, PhD

Dr. Hinrichsen demonstrates his approach to working with older clients suffering with this common disorder. Interpersonal psychotherapy (IPT) is a time-limited therapy that has been found to be effective in the treatment of depression in different age groups, including older adults. IPT focuses on one or two interpersonally relevant problems including interpersonal role disputes, role transitions, grief, and interpersonal deficits. In this session, Dr. Hinrichsen works with a 77-year-old woman who recently lost her husband following a long period of caregiving during which one of her sons died. Despite the presence of many depressive symptoms, the client is unaware that she has a major depression. Dr. Hinrichsen demonstrates effectively the process of interpersonal psychotherapy as he helps the client to understand depression, its precipitants, and the path to improvement.

Older Couples - with Paula Hartman-Stein, PhD

Dr. Hartman-Stein demonstrates her approach to conducting therapy with couples in their later years. Working with older couples involves many issues not common in therapy with younger people, including issues surrounding illness, cognitive impairment, and physical decline, all of which generally cause some stress in marital relationships. Hartman-Stein's approach is to teach couples better ways to cope with the challenges of aging with the resources they have available. In this session, Dr. Hartman-Stein works with a couple in their early 60s who have become entrenched in negative patterns of interaction. After performing an assessment, she builds rapport with the couple and begins the work of instilling hope.

Sex Therapy for Middle Age and Older Adults - with Barry W. McCarthy, PhD

Dr. McCarthy's integrative couples approach to sex therapy. This subspecialty of psychotherapy integrates sexuality issues with general therapy, focusing on the importance of sexuality in a balanced life. Dr. McCarthy's approach is to help middle-aged and older clients learn new ways to experience sexuality and eroticism instead of accepting the common notion that sexuality plays a smaller role as we age. In this session, a middle-aged woman looks for help with changes in her sex life that occurred after her hysterectomy and her husband's heart surgery. Dr. McCarthy helps her to see her sex life in a new way and to generate ways to get her husband involved in adapting to their changing sexuality.

Treating Alzheimer's Disease through Caregiver Family Therapy - with Sara Honn Qualls, PhD

Dr. Qualls demonstrates her approach to helping families care for loved ones with Alzheimer's disease.
Caregiver Family Therapy (CFT) assists families with recognizing, interpreting, and taking action to address symptoms of growing cognitive impairment while continuing to meet the needs of multiple family members. In this session, Dr. Qualls works with a young African American woman named Michelle who is married with a family. Her mother, who lives with the client's disabled sister, is becoming less and less able to take care of herself. The night before the session, her mother called 911 to accuse Michelle's sister of abuse. This false accusation is seen as a harbinger of changes that will need to be made in Michelle's sister's living arrangement because of her mother's decline. In the session, Michelle begins to realize that her caregiving is having a negative impact on her family and marriage. Dr. Qualls helps Michelle to explore restructuring the family and to develop a list of tasks that need to be accomplished to protect the well-being of her mother, sister, and herself and her family.

Videos on Psychotherapy and Older Adults