Advances in PsychiatricPsychotherapies

Treatment (2004),with
vol.older
10, 371–377
people

Psychotherapies with older people:

an overview
Jason Hepple

Abstract Psychotherapies with older people have been slow to develop, both theoretically and operationally,
in the UK. This is due to ageism and the predominance of models of psychological development
relevant to children and younger adults. Despite this, many have applied their practice and skills to
psychological work in old age psychiatry, countering the dominance of the ‘organic’ model. An
evidence and practice base exists to suggest that cognitive–behavioural therapy, interpersonal therapy,
cognitive analytic therapy, psychodynamic and systemic approaches can help in a range of psychiatric
problems in older people, including affective disorders, personality disorders and dementia. The
inclusion of older people in existing psychotherapy services and the development of networks of
practitioners whose support and supervision are encouraged are likely to be positive ways forward.

My aim here is to give readers an overview of the collective consciousness of policy makers and
psychological therapies that have been applied to clinicians. The National Service Framework for
work with older people, in order to inform clinical Older People (Department of Health, 2001) cites the
work in old age psychiatry and to encourage interest, elimination of ageism as a laudable aim, but does
training and referral where resources and practi- not go far in suggesting how this might realistically
tioners are available. Psychological therapies with be achieved. It is interesting to consider the paradox
older people have traditionally held a lowly position that discrimination based on a universal experience
in old age psychiatry and in psychotherapy generally. (ageing and death) has been relatively slow to
This is due to a number of reasons, particularly achieve public awareness compared with ‘isms’ that
ageism, which has been a great hindrance to develop- oppress minority groups in society. There may be
ment of expertise and services in this area. Negative many reasons for this: the prevalence of ageism
stereotypes about the treatability of older people and among older people themselves (discouraging the
a lack of psychotherapy theory that can speak to formation of a ‘minority group’); our need for robust
later life still have a pervasive negative effect on denial-based defences to protect against frightening
expectations and expertise. With the current high existential uncertainties (death, meaninglessness);
demand on old age psychiatry services for the assess- and the notion of the demise of ‘elderhood’ in
ment and treatment of early dementia, developments Western society in the 20th century. For a full
in services are focusing on biological models of discussion of these factors see Hepple (2004).
illness and pharmacological treatments, again at the Even at the age of 49 himself, Freud considered
expense of psychological therapies. older people (the over-50s by his reckoning)
Needless to say, this brief overview cannot ineducable (Freud, 1905). This therapeutic nihilism
investigate the topic in depth: for a more complete has had a profound effect on the development of
review see Hepple et al (2002a). both psychotherapy theory and services for older
people. Psychotherapy theory has tended to focus
on childhood development and the developmental
Background stages of infant, child and early-adult life, with later
life being neglected as a developmental phase. An
Ageism, or the discrimination against people on the exception to this has been the work of Erikson (1966),
grounds of age alone, has been slow to gain public who identified ‘eight ages of man’ in terms of
awareness in Western society. Although racism and dichotomies, with ‘generality v. stagnation’ and ‘ego-
sexism, for example, have been tackled in statute integrity v. despair’ describing the developmental
law in the UK, ageism is just surfacing in the challenges of later life. The apparent linearity of this

Jason Hepple is a consultant psychiatrist and Medical Director of Somerset Partnership NHS and Social Care Trust (Magnolia
House, 56 Preston Road, Yeovil, Somerset BA20 2BN, UK. E-mail: jason.hepple@sompar.nhs.uk). He is a clinical research
fellow of the Peninsula Medical School and is a cognitive analytic therapy practitioner and supervisor.

Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ 371

https://doi.org/10.1192/apt.10.5.371 Published online by Cambridge University Press
 Hepple

model, however, and the lack of elaboration of al, 2001) of the effectiveness of CBT v. supportive
the nature of psychological development in later life counselling on anxiety symptoms in older adults
over the 30 years since Erikson proposed it have showed CBT to be both effective and superior to
left old age psychotherapy detached from the supportive counselling in terms of improvement in
mainstream and without a firm theoretical base. In anxiety symptoms and self-rating of anxiety and
addition, the dominance of the biological or organic depression over a 12-month period.
model in old age psychiatry and neuropsychology Cognitive–behavioural therapy focuses on
has tended towards ‘brain-based’ rather than negative thoughts and their reinforcing behaviours,
‘psyche-based’ explanations for all illness and attempting to identify dysfunctional cycles and to
distress in later life, where the imaging and charting intervene with challenges to unhelpful thinking, the
of deficits takes priority over any meaningful reduction of negative and avoidant behaviours and
dialogue about shared existential fears between the introduction of positive behaviour patterns.
professional and patient. Negative thoughts can be challenged by techniques
Murphy (2000) surveyed the prevalence and that assess the evidence behind the thought, the
availability of psychological therapy services for ‘thinking errors’ that are present, the pragmatic
older people in the UK. The respondents included a effect of negative thoughts on overall well-being and
range of mental health and social care professionals, the consideration of alternative viewpoints. The
of whom 87% felt that their services failed to deliver intensity with which thoughts are held can be rated
to older people, with low expectations being reflected and monitored through treatment, and the re-
in the disproportionately low referral rates. For inforcing avoidant behaviours can be tackled using
example, less than 1% of referrals involved patients a graded exposure model. In work with older people,
over 75 years of age, although this group accounted writers in the field suggest some adaptations to CBT
for nearly 9% of the population. Interestingly, old technique, including increased emphasis on main-
age psychiatrists were less likely to refer the over- taining the focus on the work, acknowledgement of
55s for psychotherapy than were general adult feelings of guilt and helplessness following the onset
psychiatrists. Despite all these problems, many of disability and other life events and an awareness
psychotherapists, psychologists and psychiatrists of the interaction of somatisation and the physical
have used various psychotherapies with older symptoms of organic disease. Cognitive–behavioural
people with success and enthusiasm. Of particular therapy offers a structured, collaborative, brief and
note is the work of Martin (1944) and Hildebrand client-centred approach. The wide availability of this
(e.g. Hildebrand, 1990), who can be seen as pioneers therapy for younger people in the UK makes it well
in this field. Many others, who will be mentioned in positioned for further expansion into later-life work.
the sections below covering individual psycho-
therapies, have been determined to apply and
develop different theoretical approaches in their Cognitive analytic therapy
work with older people and to share their experience
and positivity. In contrast to the pessimistic starting Cognitive analytic therapy (CAT) represents a
point that psychotherapy with older people is ‘too modern integration of analytic (object relations
late’ there is hope not only that it is not too late, but theory) and cognitive psychotherapy traditions to
that for many it can be just in time. provide a brief, structured and collaborative thera-
peutic journey from past trauma into reconnection
with dialogue and meaning. In existence for less
Cognitive–behavioural therapy than 20 years, the evidence base, although in
progress, is yet to be established, but there is interest
Cognitive–behavioural therapy (CBT) is the form of in applying the model to older people and potential
psychotherapy most often used with older people. for the development of a therapy that truly speaks to
In controlled clinical studies it has been shown to later life through its emphasis on shared meaning
be efficacious in the treatment of depression, anxiety in the context of the client’s life story and the recog-
and problematic behaviours in the context of nised importance of the ‘dialogue’, both cathartic
dementia (for reviews of this literature see Teri et al and reparative, in the therapeutic relationship
(1994) and Wilkinson (2002)). In a series of studies (Hepple, 2002). Traditional concepts from psycho-
with older people in the USA by Gallagher- analytic theory and psychiatry (such as narcissism,
Thompson and colleagues (reviewed by Teri et al, borderline personality traits and post-traumatic
1994) CBT has been shown to be highly effective syndromes) have recently been applied to later life
with depressed patients in both hospital and from a CAT perspective (Hepple & Sutton, 2004).
community settings as well as in individual and Later life can be a time when coping mechanisms
group formats. A more recent trial (Barrowclough et are challenged by losses, disability and changes in

372 Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/

https://doi.org/10.1192/apt.10.5.371 Published online by Cambridge University Press
 Psychotherapies with older people

social role. It is then that pre-existing trauma and stage, leaving her outpaced and isolated. Her
low self-esteem can resurface to produce anxiety, appearance and behaviour seemed a direct regression
depression and self-destructive behaviours, which to the abused, terrified and watchful child who was
need to be understood in terms of the person’s whole paralysed into inactivity but who was trying to
communicate her pain through her gaze alone. Focus
life story. Cognitive analytic therapy can offer a
on the here and now of the shortened sessions and
coherent way of linking past and present, and may
preparedness to simply ‘be with’ Mrs Y allowed a
be well suited to work in later life because of its gradual emergence from the cocoon and hesitant
emphasis on the interpersonal and the need to find attempts at communicating the nature of the pain to
shared meaning and understanding in therapy a trusted other. Improvements in self-care and
across generational and cultural boundaries. integration into ward life occurred, and work is still
Anthony Ryle, the originator of CAT, writes: ongoing.
The case illustrates the need to establish a meaning-
‘Personality and relationships are not adequately
ful dialogue before any specific therapeutic models
described in terms of objects, conflicts or assumptions.
and techniques can be applied. It is hoped that Mrs Y
They are sustained through an ongoing conversation
will soon be able to start a formal CAT therapy in
within ourselves and with others – a conversation
order to process the trauma of her earlier abuse.
with roots in the past and pointing to the future. In
their conversation with their patients, psycho-
therapists become important participants in this
conversation and CAT, I believe, fosters the particular
Psychodynamic therapy
skills needed to find the words and other signs that
patients need’ (Ryle, 2000). This broad range of therapies, stemming largely from
the work of Freud, Klein and Jung, has been
The following case vignette demonstrates the CAT discussed widely in relation to later life (for reviews
approach in treating re-emergent trauma in late life. see Garner (2002) and Arden (2002)). Some empirical
evidence exists to suggest that psychodynamic work
Vignette with older people is at least as effective as CBT in
Mrs Y was a 67-year-old woman who had been
dealing with depression (Thompson et al, 1987).
admitted to an acute adult psychiatric unit following
Psychodynamic approaches often centre on the
a serious suicide attempt related to her divorce from
her second husband. She was treated for depression development of insight into repressed unconscious
with medication and electroconvulsive therapy but material from earlier life experience and on the
was still an in-patient 2 years later, because attempts working through of this material in the therapeutic
to discharge her had provoked immediate and relationship. Experience has shown that the client’s
serious self-harm. Although previously a highly age can be an important factor in the nature of the
competent and sociable person, she regressed into a transference and countertransference aspects of the
child-like state of withdrawal and frozen watchful- therapy. Therapists may be reluctant to acknowl-
ness. One-to-one communication was difficult owing edge the infantile needs of an elderly client because
to her monosyllabic answers, repetition of ‘I don’t of a subconscious fear of the perceived dependence
know’ and tendency to terminate interviews. Anxiety
and helplessness that they might themselves experi-
management and graded exposure to improve social
ence in old age. Erotic transference may be ignored
skills proved ineffective because of failure to engage
Mrs Y meaningfully in the work. There were or ridiculed in the countertransference, and the
outbursts of anger (e.g. if there were small delays to client’s situation may elicit in the therapist idealised
ward routine) and staff reported feeling that Mrs Y care fantasies resulting from the therapist’s un-
‘knew everything that was going on’ behind the conscious fears and concerns about their own older
penetrating stare. family members. The psychodynamic model,
It was known that Mrs Y had been sexually abused however, is likely to be well suited to working with
by a relative for much of her adolescence, but it material derived from the client’s ‘feelings of
seemed impossible to engage her in dialogue about abandonment and despair, intimacy and isolation,
this. It remained unspoken (and unspeakable). Using arrogance and disdain, stagnation and creativity
some basic principles of CAT, although not attempting
as each of us struggles with the developmental task
full therapy, Mrs Y’s keyworker conducted daily 20-
of “the third age” ’ (Hildebrand, quoted in Hunter,
minute one-to-one sessions with her in an attempt to
reconnect her with her need to be heard and in contact 1989: p. 250).
with an other. The CAT concept of the zone of
proximal development was used to establish where
Mrs Y was and how far, realistically, she might be
Interpersonal therapy
able to go from there. She was in a cocoon and unable
to venture out owing to owing to her unspoken fear. Interpersonal therapy is a practical, focused, brief,
Previous therapeutic interventions had failed to manual-based therapy that can be applied by a
match therapy aims with Mrs Y’s potential at this range of professionals after a period of basic training.

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 Hepple

Its accessibility has generated considerable interest Psychotherapy in dementia

in its use with older people, and a reasonable
evidence base exists to support its efficacy in the For a detailed review of non-pharmacological
treatment of depression in older people, both in treatments in dementia I recommend a recent APT
the acute phase and in relapse prevention (Reynolds article by Douglas et al (2004). They discuss the
et al, 1999). evidence supporting behavioural approaches in
Interpersonal therapy focuses on disturbances in improving the behavioural and psychological
current relationships, categorised into four domains: symptoms of dementia (BPSD), reviewing some of
role transition, role dispute, abnormal grief and the alternative therapy approaches and the evidence
interpersonal deficit. A range of therapeutic inter- base for the more ‘traditional’ approaches on which
ventions aim to improve communication, express I comment below. Rather than duplicate their review,
affect and support renegotiated role relationships, I will comment from a more psychodynamic and
with the effect of symptom reduction and improve- CAT perspective.
ment in functionality. Experience in applying Owing to the presence of often severe memory
interpersonal therapy to work with older people has deficits in people with dementia, one-to-one psycho-
suggested that it is directly applicable to the therapy is usually avoided. From an interpersonal
relationship and developmental issues relevant to and systemic point of view, however, the organic
people in later life. For a review of this area see Miller pathology itself is but one aspect of the individual’s
& Reynolds (2002). situation, and disability and distress can often be
understood clearly in terms of psychological models
rather than as neurological symptoms such as
Systemic (family) therapy disinhibition or apathy. Laura Sutton has recently
restated Tom Kitwood’s ‘malignant social psy-
Although the evidence base for the use of systemic chology’ of dementia care in the reciprocal-role
approaches in work with older people is sparse, a terminology of CAT (Sutton, 2004). Maintaining a
model that looks at individuals in the context of their view of the person’s pre-dementia personality
wider family and social system seems to have wide structure and attending to the repetition of unhelpful
applicability (Pearce, 2002). A systemic approach role-play in the professional–client relationship is
may be particularly helpful in the context of a promising way of processing the challenging
communicating and processing the diagnosis of dynamics of dementia care.
dementia in a family setting and also in unravelling Over the years, various fairly superficial
the reinforcing factors in dysfunctional somatising approaches have been used in dementia care, often
and sick-role behaviour in older adults (Qualls, using a group approach. Reminiscence therapy,
2000). Systemic approaches can be used pragmatic- reviewed by Thornton & Brotchie (1987), is under-
ally both in one-off therapeutic assessments and going something of a resurgence in the UK. The idea
in more formal therapy sessions following an of improving communication and self-esteem
established family therapy model. through reminiscence is undoubtedly helpful.
The systemic approach recognises that presenting However, there is a tendency for group reminiscence
symptoms in the index patient may result from (remembering the sights and sounds of the Second
dysfunctional dynamics in the wider matrix of World War, for example) to lump individuals into a
relationships surrounding the individual. By using ‘cohort’ more imagined by the younger carers than
techniques such as circular questioning (e.g. ‘What remembered by the older people themselves. At its
do you think X would say to that?’), positive worst, this behaviour verges on the ageist.
connotation (e.g. ‘You are such a close family that Reality orientation is widely used in dementia care
sometimes you care too much’), paradoxical and it works on the premise that people with
intervention (e.g. ‘So it seems that you have solved dementia will benefit from environmental and inter-
all your difficulties and don’t need our help any personal intervention that reorients them in terms
longer’), reframing (e.g. ‘It seems as if X is flagging of person, place and time and that corrects their mis-
up the distress on behalf of the whole family’) and perceptions and forgotten reality. This approach has
exploration of the shared genogram (family tree), been manualised in an ambitiously titled publication
therapy may tip the system into positive change. The Way to Reality (American Hospital Association,
The availability of professionals skilled in system 1976). Many working in dementia care, however,
approaches is likely to be highly beneficial as a find that constant reality orientation can cause
consultative tool for those working directly with distress and the cyclical remembering and forgetting
clients in old age psychiatry, who are well aware of of losses and disabilities. Sutton (2004) calls this
the challenging family dynamics often uncovered interaction ‘outpacing to unbearably outpaced’,
by mental illness in late life. remarking that it can recreate the most distressing

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https://doi.org/10.1192/apt.10.5.371 Published online by Cambridge University Press
 Psychotherapies with older people

aspects of cognitive impairment repeatedly in the family or systemic relationships. Systemic (family)
care setting. An opposite approach, which gained therapy is indicated if at least some of the system
many devotees in the 1970s, is Naimo Feil’s can be engaged in it.
validation therapy (Feil, 1982). The symbolic content
of dialogue and interpersonal interaction is explored
Somatisation disorders
and, where possible, shared and validated by the
carer, with no attempt to re-establish orientation Cognitive–behavioural therapy is probably the first-
in reality. This approach can be cathartic and line approach, but if the somatic or dissociative
reconnecting, although it requires a very active symptoms can be traced to earlier trauma a more
therapist to maintain engagement. In its broader exploratory therapy such as CAT or psychodynamic
applications, this approach has permeated many therapy may be needed.
dementia care settings.
Psychological approaches
What for whom? to dementia care
The choice of psychological approach will largely Insights from psychodynamic theory and CAT can
depend on availability of expertise, which is often contribute to an understanding of the role-play
sadly lacking because psychotherapies are still between the carer and the person with dementia and
regarded as being unnecessary or ineffective for older help prevent interaction that reinforces the isolation
people. In an ideal world, however, a range of and alienation experienced. Behavioural approaches
therapies would be available, and given that some may be helpful for clusters of repetitive behavioural
require considerably more time and resources than disturbances in more severe dementia. Family and
others, the following is a guide to deciding what systemic approaches can be useful in exploring a
might be best for whom. diagnosis of early dementia. A general approach
based loosely on the principles of validation therapy,
with time for reminiscence and life review, is likely
‘Uncomplicated’ depressive illness to provide a humane theoretical backdrop to
Cognitive–behavioural or interpersonal therapy may dementia care in many settings.
be offered in the first instance with or without
pharmacological treatment. Both therapies may be
useful in relapse prevention in those with recurrent
Developing services
depression. Interpersonal therapy may take pref-
A psychological perspective is a key part of the
erence where obvious tensions exist in current
biological, psychological and social triad under-
relationships, whereas CBT may suit a more
pinning good psychiatric treatment. However, it is
cognitively minded patient. Cognitive–behavioural
probably unreasonable to expect a large input of
therapy should also be the first-line approach for
resources for specialist training and the appointment
pronounced anxiety symptoms and panic with
of dedicated therapists to work with older people. A
avoidant behaviours.
gradually increasing awareness of, and skills in,
psychotherapies among ‘front-line’ workers will
Depressive illness and borderline probably deliver the most overall benefit.
or narcissistic personality traits Where services exist for adults of working age then
age barriers to referral should be removed and old
Patients with depressive illness complicated by age service professionals should work in collabor-
antecedent borderline or narcissistic personality ation with colleagues in general adult psychiatry.
traits often have a history of traumatic experience in One way of doing this is to set up ‘psychological
childhood or earlier in their adult lives and exist therapies networks’ within trusts or institutions.
either in a highly dysfunctional systemic context or Box 1 outlines the procedure for establishing such a
in relative isolation following severing of close network, which my colleagues and I have described
interpersonal links. Cognitive analytic therapy or in greater detail elsewhere (Hepple et al, 2002b).
psychodynamic therapy is the treatment of choice. The community psychiatric nurses, social workers,
occupational therapists and in-patient and day
Depressive illness in dysfunctional patient staff engaged in psychotherapeutic work
family systems with patients and clients should be supervised by
experienced therapists. A consultation model of
Depressive illness in late life is sometimes compli- supervision rather than a formal therapy model can
cated by enmeshed and ‘high expressed emotion’ be helpful to both patients and staff (Sutton, 2004).

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 Hepple

Box 1 How to establish a psychological therapies network for older people

• Form an executive committee to oversee the evolution of the network and to liaise with purchasers,
funding organisations, users and carers, and the wider health services. The committee’s members
should be senior practitioners and managers working for the organisation as a whole.
• Remove all age criteria from operational policies relating to psychological treatments.
• Encourage professionals to link across the boundaries of age-specific services and to find a shared
interest in a particular psychological therapy.
• Conduct a survey to identify who is currently practising which therapy, what training they have had
and what practitioner supervision structures exist.
• Using the available evidence and local experience, identify the psychotherapies that the organisation
wishes to provide and define how much (in terms of practitioner hours per week) of each should be
available in each locality.
• Identify practitioners and practitioner supervisors in each therapy, paying heed to the requisites of the
relevant national psychotherapy organisations (such as the British Confederation of Psychotherapists).
• Allocate protected time to each practitioner to engage in psychotherapy work.
• Appoint a coordinator for each locality to act as a troubleshooter and manager of the practitioner
supervision structures.
• Arrange for the coordinator to meet each practitioner at regular intervals to discuss their role within
the network and their training needs.
• Ensure that those working with older people have the same access to training and supervision as
those working with younger clients.
• Develop protocols for allocating a particular client to a particular therapy.
• Collect or create information on the therapies being offered to enable clients to express informed
preferences.
• Identify more-experienced practitioners to provide psychotherapy assessments in difficult cases and
to act as consultants in the application of psychotherapeutic principles in day-to-day clinical work.
• Decide under what circumstances the person delivering a psychotherapy can also be the client’s care
coordinator, responsible medical officer or equivalent.
• Establish a regular programme of education, training and sharing of ideas and experience.
• Establish systems for auditing practice, outcomes and clients’ views.

Moving forward they need to help their patients. Psychiatrists will

always play a key role in assessment and in
A range of psychological therapies have proved encouraging other staff’s understanding of each
themselves effective in the management of older patient in their biological, psychological and social
people with mental health problems, both in context. To honour this role, we must ensure that
controlled trials and the growing body of clinical the psychological dimension does not continue to
experience and case material in the literature. There take a back seat to biological and social-care models.
is little prospect of funding for large-scale controlled
studies involving older people, and if a therapy is
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