Psychological theories and their applications in gerontology

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Gerontology and psychology: Approaches to mitigating the negative aspects of aging

Youth is a temporary state: most human beings will eventually become old. Yet psychology has traditionally devoted relatively little analysis to the inevitable challenges of aging, and instead chosen to focus on childhood and adolescent development. This has changed in recent years, given the widespread aging of the worldwide population. "The number of Americans age 65 and older is projected to comprise about 20% of the nation's population by the year 2030. With a growing elderly population, greater attention has been devoted to the lives of seniors and toward ensuring the physical and mental health of individuals as they move toward later life" (Facts sheet on aging, 2001, AABT, p.1). Cognitive behavioral theory (CBT), psychoanalytic theory, and behaviorism have all been shown to be helpful in enabling seniors to cope with changes in their lives, spanning from chronic illnesses to dealing, with retirement, to the loss of a spouse and other age-related social and physical issues.

The father of psychoanalysis Sigmund Freud famously stated "that older people are not good candidates for psychotherapy" because all human beings effectively stop learning at the age of age fifty (Knight & Satre, 1999, p. 4). Even while many of Freud's theories have been debunked, aging is still often conceptualized according to a "loss-deficit model of aging, which portrayed the normative course of later life as a series of losses and the typical response as depression" (Knight & Satre, 1994, p.4). Depression in the elderly was thus normalized by the psychiatric profession, which simply encouraged rather than discouraged such a response in the client. Life was viewed as inevitably leading to fewer fruitful activities and social relationships. In fact, "psychological disorders are less common in old age than middle age. The incidence of major depression, anxiety, and drug abuse all decrease with age. Some core symptoms of chronic psychological disorders may even improve with age. For example, "hallucinations and delusions among individuals with schizophrenia tend to decrease with age," as in the case of Noble-prize winning economist John Nash (Facts sheet on aging, 2001, AABT, p.1). Social isolation and chronic health conditions can increase the likelihood of depression in the elderly but these symptoms are far from inevitable and must not be seen as such by the therapist, regardless of what technique he or she uses in his or her practice.

While the father of psychoanalysis took a dim view of the possibilities of human change at the end of life, recently cognitive therapy's ability to "provide clients with a more rational and realistic understanding of the self and the world" has been used with great success amongst older adults (Knight & Satre, 1994, p.4). Behavioral therapies and cognitive behavior therapies (CBT) are goal-directed therapeutic techniques that set specific short- and long-term goals for the therapeutic process and the client. They "often focus more on the current situation and its solution, rather than the past. They concentrate on a person's views and beliefs about their life, not on personality traits" (Facts sheet on aging, 2001, AABT, p.4).

It must be admitted that behavioral therapies and CBT were initially designed to deal with problems of childhood, pubescence and adolescence such as conduct disorders, ADHD, obsessive-compulsive disorder, and borderline personality disorders. It was assumed that older individuals were less flexible and able to make the specific, concrete changes demanded by the therapy. Individuals undergoing CBT often have a particular 'assignment' every week, to help them change their behaviors. For example, someone with social anxiety might be given an assignment to take public transportation or talk to a stranger.

While "cognitive behavioral interventions, like those of other therapy systems, are based on work with younger adult clients" that does not mean they are ineffective with other population groups (Knight & Satre, 1994, p.13). The deficits of old age regarding the ability to change behavioral patterns may be less than previously thought: for example, crystallized intelligence, such as general knowledge, vocabulary, and information shows little change as a result of the aging process until age 70 and even later in some individuals . "Changes after 70 in average level of intellectual abilities are observed but are neither global nor universal, and may be due to early stages of dementing illness or to illness-related declines" rather than are universally endemic to the aging process itself -- many older adults exhibit no deficits in these capabilities (Knight & Satre, 1994, p.6). Therapists may simply need to adapt their CBT stratagems to treat the needs of their older client.

Traditionally, CBT has deployed a Socratic method of therapy, continually questioning the client about his or her irrational suppositions about the world. For example, someone with obsessive-compulsive disorder might be forced to answer what would happen if he was 'contaminated' with germs and did not wash his hands. Someone with borderline personality disorder might be asked why she believes her life will be over if her boyfriend leaves her. With older adults, "the therapist must rely less on the client's inferential reasoning and problem-solving abilities. The therapist may need to lead the older client to conclusions rather than giving suggestions and expecting the client to infer the applications" (Knight & Satre, 1994, p.10).

Not only is there a loss of some fluid intelligence capability in older adults, but the CBT therapist must remember (especially if he or she is younger than the elderly person) that the negative thinking patterns established by the adult have had many more years to become entrenched. Even a chronically depressed teen has only engaged in nonproductive thinking for a single life phase -- for an adult, he or she may have been depressed or engaged in rigid behaviors and ways of thinking for decades. The difficulties the elderly patient copes with may be partially age-related, but the patient may be using the same unproductive coping techniques he or she adopted many years ago. The CBT therapist working with the elderly may need to be more directive in his or her manner and set a longer time table for smaller, realistic goals for the older adult to achieve.

The therapist should also remember that many of the problems the elderly person is coping with may actually be more 'real' or intractable than the problems of a young person with identity or anxiety issues. The problems of sickness, including chronic illnesses like Parkinson's and even arthritis are not simply irrational constructs of the elderly person's mind. But a therapist can help the older adult view unwelcomed changes in a more productive fashion. For example: "an older adult needing assistance from her daughter may be both happy that the daughter is willing to assist and sad that she is a burden on the daughter who has multiple other responsibilities. Rather than considering the cognition about burden as irrational, it may be helpful to construe the daughter's willingness to care as a sign of her love and also to elaborate the observations that lead to concerns about being a burden and to encourage problem solving strategies to limit the burden as much as possible" (Knight & Satre, 1994, p.13).

Psychotherapy can even prolong an individual's life, by giving them a way of viewing themselves with dignity and seeing their age or disability in a more productive fashion: "One of the biggest psychological challenges of growing old, it seems, is having one's body fall apart. Loss of mobility can be even more devastating than loss of sight or hearing. And while a psychiatrist who works with nursing home patients reported that she has been successful at helping some adjust psychologically to their physical decline, she has not been able to help others…Elderly persons who break a hip rarely live more than six months afterward…because of the physical trauma that results from a hip break, but also because of the psychological trauma that ensues from losing mobility" (Arehart-Treichel, 2001).

CBT's probing approach can be very useful: older adults still show a profound need for social relationships. In fact, rather than showing global memory loss, older adults without dementia, "recalled a greater proportion of emotional information than did younger adults. These findings suggest that emotion-related cognitions become increasingly important as adults age" (Knight & Satre, 1994, p.10). Connecting with a therapist and being able to view his or her life as meaningful and still a work in progress can be profoundly beneficial for the elderly.

However, not only CBT has been used with success to treat the needs of the elderly. Despite Freud's personal hostility to the processes of aging, modern psychodynamic theorists have advocated the applicability of the psychoanalytic approach in gerontology. "Empathic listening, exploratory inquiry, and interpretation and clarification of unconscious determinants are essential parts of psychodynamic therapy. All of these techniques are used with both older and younger patients in psychodynamic therapy" (Morgan, 2003, p. 1592). As with CBT, however, adaptability to the needs of the older client is essential: "The main distinction that therapists should make between older and younger groups is that as people age, they become more physically and psychologically diverse from one another. 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).