For example, one-75-year-old may be running a corporation, whereas another may need nursing home care" (Morgan, 2003, p. 1592).
Additionally, the long duration of psychoanalytic therapy may demand that even for very vibrant older individuals, a more directive approach is necessary for the therapist to speed things up and meet therapeutic goals within a realistic time frame. This can be challenging to the analyst, as the patient's unconscious beliefs and associations, given the person's age may be more complex, personal, deeply-rooted and therefore harder to eradicate. Additionally, "unfocused reminiscing may not be suitable for persons who have trauma histories, such as Holocaust survivors, or for persons who have early dementia" (Morgan, 2003, p. 1592). However, it was the psychoanalytic theorist Erik Erikson who first developed a stage-based theory about the needs of the aged and Erikson's theory can inform the process of psychoanalysis in an effective manner and provide a philosophical structure for the course of treatment.
Erik Erikson said that "late life is about putting one's life into perspective and negotiating between ego integrity and despair. The expectable events of aging, such as retirement or relationships with adult children and grandchildren, often serve as an impetus for self-reflection" and therefore are appropriate for psychotherapists to explore (Morgan, 2003, p. 1592). Erikson wrote that the essential conflict of maturity is one of "integrity vs. despair: as an adult reaches the end of her life, she looks back at what she has or hasn't accomplished, and feels a deep sense of fulfillment or at least an acceptance of the life she has lived (out of which will come wisdom), or alternatively, she descends into anguish or despair at having not lived a full and vital existence" (Armstrong 2007).
Psychoanalytic techniques involve the client making free associations with words after being prompted by the therapist and probing unconscious urges and belief patterns. Psychoanalysis requires a great deal of trust between patient and therapist and has a more discursive and less rational technique than the Socratic 'learning' therapy of CBT, where individuals are questioned about irrational behavioral patterns. Psychoanalysis can be lengthy and costly, and this may be an issue for patients who have a limited budget for therapeutic sessions. From a purely practical standpoint CBT's shorter duration ensures that the client is able to attend all of his or her sessions, if transportation assistance is needed. Also, the deep self-searching, lack of a goal of psychoanalysis and its frank talk about sexuality may make some older adults uncomfortable, depending upon their personal background. Still, like CBT, psychoanalysis encourages individuals to confront irrational beliefs and can be useful for breaking very entrenched life patterns. For example: "an 80-year-old woman resisted therapy, saying 'psychiatrists can't change old people.' With time this resistance was understood as related to a long-standing oppositional pattern, as well as to the woman's difficulty of directly asserting herself" (Morgan, 2003, p. 1592).
Even patients with dementia can show significant improvement upon receiving appropriate psychotherapy. While "people with dementia more often than not have impairments in language function and are therefore considered unsuitable" candidates, psychodynamic therapy, while not improving the patient's condition, did result in a "subjective benefit for both patients and care-givers" (Junaid & Hegde 2007, p.18). "The practice of any form of psychotherapy is based on truth, a clear understanding of the illness, its prognosis and management" including for patients with dementia (Junaid & Hegde 2007, p.18). Psychotherapy can better enable clients to deal with their new dependencies, as well as the difficulties of their primary caregivers.
The benefits for caregivers of patients with dementia should not be underestimated. Having a family engage in counseling through the use of CBT can encourage the family unit to set reasonable goals for all members to manage the illness of the afflicted individual, as well as to help the affected person him or herself. The family's rational and irrational beliefs regarding the older person's illness, as well as their own assumptions of who should care for the person can benefit from therapeutic and third-party intervention. Similarly, psychoanalysis can be valuable in understanding different family's member's senses of worth and efficacy when dealing with an afflicted individual.
For patients with Alzheimer's disease or dementia, supportive therapy can become an important component of treatment. Supportive therapy is a type of "psychological treatment given to people with chronic and disabling psychiatric conditions for whom fundamental change is not a realistic goal. This, of course, suggests that supportive therapy is one of the most commonly practiced types of psychotherapy… the therapist's primary role in supportive psychotherapy is to support and strengthen the individual's potential for better and more mature ego functioning in both adaptation and developmental tasks" (Junaid & Hegde 2007, p.18). Coping mechanisms and affirming the patient's sense of competence is essential, while still making them "aware of the reality of their life situation, e.g. Of their own limitations and those of treatment, and of what can and cannot be achieved" (Junaid & Hegde 2007, p.18). Some therapists even use conventional psychotherapy with individuals "succumbing to Alzheimer's disease," taking "a history, just as he would with any patient, starting with the patient's earliest memories and continuing up to the present. This storytelling...helps the pre-Alzheimer's patient regain, at least for a while, a sense of coherence about his or her life" (Arehart-Treichel, 2001).
Parkinson's disease is another common ailment amongst the aged that can benefit from therapy. While it does not affect cognitive behaviors to the same extent as Alzheimer's disease or dementia, it is often accompanied by depression for biological reasons and the deficit of the brain chemical dopamine in patients. (Individuals taking certain anti-psychotic medications can manifest Parkinson-like symptoms such as twitching and a lack of effect, because the drugs retard the production of dopamine in the brain). In one study of Parkinson's patients, 20% of 176 patients "had required psychiatric attention for major depressive illness before the appearance of motor disabilities" reflecting the psychological effects of the illness (Todes & Lees, 1985).
Even before their illness manifested itself, "a review of the extensive descriptive literature suggests that many Parkinson's patients exhibit an emotional and attitudinal inflexibility, a lack of affect and a predisposition to depressive illness, which may antecede the development of motor abnormalities by several decades. Introspective, over-controlled, anhedonic personality traits together with suppressed aggresivity are frequently found. It is unclear whether these behavioral patterns are relevant aetiological factors or prodromal symptoms of the disease" although it is speculated that the low levels of dopamine that accompany Parkinson's may be partially to blame (Todes & Lees, 1985). Treating the complications of major depression, the loss of mobility of Parkinson's, and the general adjustments of age are just some of the factors that can be addressed within the context of therapy for Parkinson's patients.
And "even when psychotherapy does not transform the minds, hearts, and behaviors of older persons, it can still benefit them in less dramatic ways… it can sometimes help patients who have been estranged from their children become reunited with them. It can lead to better self-understanding" which is valuable at any age" (Arehart-Treichel, 2001). One problem with finding funding and support for therapy amongst the elderly is that not all studies have shown therapeutic intervention to be cost-effective in terms of showing demonstrable improvement: In a 2007 study of depressed elderly patients: "Cost-effectiveness planes indicated that there was much uncertainty around the cost-effectiveness ratios. CONCLUSIONS: Based on these results, provision of IPT [interpersonal psychotherapy] in primary care to elderly depressed patients was not cost-effective in comparison to CAU [care as usual]" (Bosmand 2007).
The elderly, particularly in studies which do not distinguish between patients with or without dementia, may not show as robust a response to therapy, but the alteration may still be discernable. It is essential that ways to measure the elderly person's positive or lack of response to therapy be clearly defined. The ways of measuring young person's positive benefits from therapy (such as greater autonomy, physical status, supporting one's self, honoring family obligations) may not be applicable to older patients. Furthermore, health complaints can also interfere with the elderly person's ability to respond to treatment in a robust fashion: the person may 'decline' but decline less precipitously than if they had not had therapy.
Other studies, with specific population groups and highly targeted approaches have shown a statistically significant impact. In "patients aged over 65 years, the interaction of diabetes and depression has predicted increased mortality, complications, disability, and earlier occurrence of all of these adverse outcomes. These deleterious effects were observed even in minor depression, where the risk of mortality within 7 years was 4.9 times higher compared with diabetes patients who did not have depressive symptoms" (Petrak 2010). The additional increase in health-service costs of 50%-75% when depression occurs together with diabetes, combined with the fact that people with diabetes are twice as likely to…