Cognitive behavioral therapy (CBT) is an effective psychological intervention
in adults with neurotic, and more recently, psychotic disorders.
However, it tends not to be the treatment chosen for older adults with
these disorders.
A review of the referrals to the Behavioral Psychotherapy Unit at the
Maudsley Hospital, London, UK over a 25-year period showed that only
1.7% were aged 65 or over. Despite this, they did as well as the younger
adults in therapy. It would appear that medication is preferred to psycho-logical
therapies for these patients, despite the possible side effects for this
group that may already have poor vision or unsteady gait. However, a few
studies have shown that CBT can be used effectively with older adults in
the treatment of both anxiety and depression.
Having qualified as a cognitive behavioural psychotherapist at the
Institute of Psychiatry and the Maudsley Hospital, I too had concerns
when returning to a mental health of older adults service. All previous
graduates of this course returned to working with younger adults, some
in specialist fields or research. I was returning to an area where there
was no established CBT service. Would there be sufficient individuals
suitable to treat? Was a CBT service for older adults feasible?
These worries proved unfounded; 70 referrals were made to a sole therapist during one year. The range of referrals received was comparable to
that seen in a younger adult service: obsessive-compulsive disorder, agora-phobia,
depression and even a 70-year-old with a lifelong bird phobia!
Not only did this group benefit from CBT (62.5% of subjects showed moderate
to marked improvement in post therapy which was maintained up
to six months in follow-up), but also the mean number of sessions was 6.3 (SD ± 3.8) ranging from 1 to 18. This figure is slightly lower than that for younger adults. Indeed, older adults showed a strong commitment to therapy often not seen in younger adult services. This was high-lighted in the lower non-attendance rate; 4% in this client group as
compared with 30% in younger adult services.
The interventions used with this group did not differ significantly from
those used when working with younger adults. Some adaptations were
needed with some clients—for example, clinical rating scales were
enlarged if vision was impaired. To foster understanding of the ration-ale
behind the various techniques, available literature was given and
used more often, in addition to the usual verbal explanation given with-in
therapy.
This successful CBT service has been established within the framework
of a Specialist Psychological Therapies Service (SPTS) for older adults.
The SPTS is a tertiary level service providing CBT, family therapy and
psychodynamic psychotherapy throughout the directorate, and continuing professional development opportunities for staff of all disciplines
wishing to learn and apply new therapy skills.
Ageist attitudes sadly remain when treatment options are considered for
older people with anxiety and affective disorders. Psychotherapy is still
viewed as mainly for the white, middle class and young. Raising clinicians’
awareness of the positive benefits of using CBT with this group
can be the first step to changing this view. Much ad hoc therapy is
occurring in various centres, but this often goes unrecorded. More published
material on either research trials or case reports needs to be
encouraged to ensure that CBT is considered—as in younger adults –
to be a first-line treatment of choice.
Deborah Walker is a Cognitive Behavioural Psychotherapist in Mental Health of Older Adults,
Lewisham and Guys, South London and Maudsley NHS Trust. She trained as a Cognitive Behavioral
Psychotherapist at the Institute of Psychiatry in London under the direction of Professor Isaac Marks. Since
qualifying she has set up and led a CBT service for older adults within a specialist psychological therapies service
at the South London and Maudsley NHS Trust. The service offers specialized clinical intervention alongside training opportunities for staff.
