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Studies of Counseling Effectiveness with Older Persons: Diagnosable Disorders
Studies of Service Use
Although Roth and Fonagy (1996,p. 323) provided only one survey from the British Department of Health, published in 1994 regarding initial contacts of clients 65 years of age and older with British clinical psychologists, as evidence to support the assumption that older adults receive inequitable access to psychological treatment, they identified several reasons for apparent underutilization of psychological services. These reasons include reluctance by therapists to treat older adults; lack of identification of older adult psychological problems by primary care physicians; and incorrect diagnosis of depression as dementia, which results in a low rate of referral for psychological treatment.
Black, Rabins, German, McGuire, and Roca (1997) noted that older adults' underutilization of psychological services might be related to unrecognized or unacknowledged mental health problems in this population and their lack of Medicare insurance or Medicaid. Black et al. used interviews and assessment instruments to study the use of psychological services and the need for these services among 371 older residents living in six public housing developments in Baltimore, Maryland. The majority of the participants lived alone (95%), were African American (95%), and were female (84%). Of these participants, 33% indicated they had used mental health services, but only 4% indicated they had received these services from a mental health specialist. Most of the participants who reported receiving mental health services said that they received these services from a primary medical care provider. More than half the participants who were identified through the interviews and instruments as being in need of mental health services indicated that they had not received mental health services of any kind in the previous 6 months.
Black et al. (1997) found that few of the participants who seemed to have psychiatric disorders rated their mental health status as "poor/very bad," possibly indicating that many were unaware of their need for mental health services. The authors also found a strong correlation between having Medicare insurance and the use of mental health services. Having Medicaid coverage correlated with the use of mental health services among the noncognitively impaired participants. Results from this study indicated that the awareness of a mental health problem and having insurance that covers mental health services are factors in the use of services by some older adults.
General Outcome Studies
More recently, Kennedy and Tanenbaum (2000) reviewed the literature for evidence of the efficacy of psychosocial interventions with older adults. They noted that although most studies had limitations (such as being conducted in academic settings with self-selected participants who were relatively independent), results from the studies indicated that age-related adaptations of interventions might be necessary with older adults to optimize outcomes. These adaptations include special consideration for any medical comorbidity, regard for the older adult's cognitive capacity, and recognition of the role of family members and caregivers. Therapeutic goals may be modified to include increased self-reliance, reduced primary-care-service needs, improved social or family interaction, and long-term health care planning. Kennedy and Tanenbaum concluded that short-term, focused psychotherapy interventions directed at clinical problems and treatment goals are especially suited for work with older adults. These findings contrast with the earlier studies summarized by Roth and Fonagy (1996), which suggested that older adults may require longer treatment involvement for successful outcomes.
Studies of Effectiveness of Specific Interventions for Mental Health Disorders
Anxiety disorders. It is difficult to determine the prevalence rates for anxiety disorders among older persons, partly because older persons underreport symptoms and partly because high rates of symptoms are reported in subclinical populations (Smyer & Qualls, 1999). As many as one third of older adults may experience significant anxiety in relation to their life circumstances at any given point in time, making anxiety disorders among the most prevalent mental health problems in later life. Anxiety frequently coexists with depression in older adults and is associated with such diverse causes as marital or family conflict and major physical illnesses such as cardiac disease; hence, differential diagnosis is difficult.
Roth and Fonagy (1996) noted that the state of research concerning treatment approaches for anxiety disorders in later life is severely insufficient. They reported the results of only one study concerning anxiety disorders, which found short-term cognitive-behavioral interventions to be effective with a small sample of outpatients, some of whom were also diagnosed with or showed symptoms of additional disorders such as depression, hypochondriasis, and serious medical conditions. Using the evidence from this single small-scale study, Roth and Fonagy (1996) concluded that evidence exists for successfully treating anxiety in older adults using cognitive-behavioral techniques, which have also been shown to work with younger adults.
Stanley and Novy (2000) reviewed additional research that yielded positive results using cognitive-behavioral interventions to treat older adults diagnosed with anxiety disorders. The techniques used in multiple studies included rational emotive therapy, cognitive, interventions, relaxation, and meditation. Although the samples in these studies were small, the treatment durations were short, follow-up evaluation was infrequent and, in all but one study, occurred shortly after the termination of treatment, and methods were very limited, Stanley and Novy identified these studies as a basis for encouragement that cognitive-behavioral interventions can be useful with older adults diagnosed with anxiety disorders.
Depression. Depression has often been noted to be the most significant and widespread mental health challenge of later life, with major depression affecting as many as 15% of older persons at any point in time and contributing to high rates of suicide, especially among older White men (Smyer & Qualls, 1999). Roth and Fonagy (1996) examined outcome research for older adults using individual psychological approaches, group therapies, and bibliotherapy for the treatment of depression. Each approach was successful to some degree with some client groups.
Scogin and McElreath (1994) reviewed 17 comparative studies of psychosocial treatments for depression, published between 1975 and 1990, to determine the efficacy of psychosocial treatments for depression in older adults. Between 16 and 162 older adults participated in each study, and the mean number of participants was 45. The mean ages of participants ranged from 61.95 to 85.0 years, with an overall mean age of 70.5 years. In some studies, the participants were identified as having subclinical depression, and other studies used only participants who were diagnosed with major depression, but most studies evaluated psychosocial treatments with a mixture of participants who had either subclinical depression or major depression. The mode of therapy varied, with 5 studies using individual treatment, 2 studies using self-administered treatment, and the remaining 10 studies using group treatment. Therapists varied by study and included psychiatrists, psychologists, social workers, and psychology graduate students. Psychosocial treatments were compared with no treatment, pill placebos, attention, and unstructured reminiscence. Some of the different approaches (behavioral, interpersonal, psychodynamic, reminiscence, and supportive) were compared with each other when studies offered direct comparisons.
Scogin and McElreath (1994) used posttreatment scores of experimental and control groups to determine the effects of treatment. Their review yielded an overall effect size of 0.78, an effect size of 0.85 for seven studies using cognitive therapy, and an effect size of 1.05 for eight studies using reminiscence therapy; all effect sizes were in relation to no treatment or a placebo condition. These effect sizes suggest that psychosocial interventions provide effective treatment for older adults who experience depressive symptoms. Comparisons of different psychosocial approaches did not indicate superiority for any particular psychosocial treatment modality.
The primary outcome research concerning individual psychological approaches used in the treatment of later-life depression reported by Roth and Fonagy (1996) examined the efficacy of behavioral, cognitive, and brief psychodynamic therapies and no treatment in an outpatient population (Thompson, Gallagher, & Breckenridge, 1987). One hundred-twenty people 60 years of age or older who were diagnosed with major depressive disorder were randomly assigned in equal numbers to four groups-three treatment groups and one delayed-treatment control group. The random assignment was somewhat constrained to create comparable groups based on age, sex, severity of depression, and presence of symptoms. Ninety-one of the participants completed the study. Participants in the treatment groups received 16 to 20 sessions of individual therapy over a 16-week period. In the behavioral approach group, treatment focused on increasing participation in social activities through social reinforcement. In the brief psychodynamic approach group, treatment relied primarily on the therapeutic relationship to develop participant insight into problems and create plans for change.
Roth and Fonagy (1996) cited two studies that provided evidence supporting the use of group therapies with older adults experiencing depression. In one study, psychodynamic group therapy and cognitive-behavioral group therapy approaches were compared and found to be equally effective in reducing levels of depression in 20 community residents, 55 years of age and older, who were diagnosed with major depressive disorder (Steuer et al., 1984). Participants were assigned to one of four treatment groups led by cotherapists who followed a treatment manual for either psychodynamic group therapy or cognitive-behavioral group therapy. A control group was not included. Comparisons of observer-ratings and self-ratings captured at intervals over the 9-week treatment span indicated that participants from both treatment conditions improved in all measured areas, which included symptoms of depression and anxiety. Although no clinical differences were observed, statistical differences from one measure suggested that symptoms of depression in the cognitive-behavioral group participants may have decreased more than did symptoms of depression in the psychodynamic group participants. No follow-up measures were taken, thus long-term effects of treatment were not evaluated.
In another study, the use of a long-term support group after hospital discharge was found to prevent relapse and reduce the number of patients referred again for treatment and readmitted to the hospital (Ong, Martineau, Lloyd, & Robbins, 1987). In this study, 20 participants, with a mean age of 70 years, who were diagnosed with depression were randomly assigned to either a support group or a control group. The coleaders of the support group used psychodynamic theory and problem-solving techniques as their main therapeutic approaches. At the start of the 9-month study, all participants were living in the community. Pre-and posttreatment clinician-rated measures and archival data were used to evaluate the effects of the support group. During the 9 months of the study, most of the members of the control group were referred again for treatment or readmitted to the hospital, and one member of the control group attempted suicide, whereas no members of the support group were referred again for treatment or readmitted or attempted suicide. The results suggested that the use of a long-term support group after hospitalization discharge may be effective in reducing relapse of depression in older adults.
Roth and Fonagy (1996) also reported a study that evaluated the efficacy of self-help books with older adults who are mildly and moderately depressed (Scogin, Jamison, & Gochneaur, 1989). Media announcements were used to recruit 67 community-dwelling participants 60 years of age and older who had depressive symptoms. After screening, participants were randomly assigned to a cognitive bibliotherapy group, a behavioral bibliotherapy group, or a delayed-treatment control group. Participants in the cognitive bibliotherapy group received a cognitive therapy self-help book, and participants in the behavioral bibliotherapy group received a behavioral therapy self-help book. They were instructed to read the book provided. Follow-up during the following 4 weeks consisted of telephone calls, lasting approximately 5 minutes, during which researchers answered any questions about the reading material. Participants in the delayed-treatment control group were also contacted weekly for 4 weeks before being assigned to a bibliotherapy group. Data from self-report questionnaires and behavioral observations were used to measure general depression, cognitive features of depression, and behavioral aspects of depression. The results revealed a clinically significant change in levels of depression when either cognitive or behavioral therapy self-help books were used. The 44 participants who completed the study retained these gains at 6-month and 2-year follow-ups.
In summary, a variety of interventions have been demonstrated to be effective in treating older persons diagnosed with subclinical or clinical depression. These include reminiscence; individual behavioral, cognitive, and brief psychodynamic therapies; group psychodynamic and cognitive-behavioral therapies; and self-help bibliotherapy.
Sleep disturbances. Sleep disturbance, including difficulty falling asleep or staying asleep, is common in later life (Bootzin, Epstein, Engle-Friedman, & Salvio, 1996). Roth and Fonagy (1996) cited a study by Friedman, Bliwise, Yesavage, and Salom (1991) that demonstrated the effectiveness of relaxation methods, in comparison to sleep restriction, in assisting 22 mildly depressed older adults, living in the community, who complained of sleep disturbance. The average age of the participants was 69.7 years, and participation included 2 weeks of baseline reporting, 4 weeks of treatment, and 2 weeks of follow-up. Although they were unable to locate adequate outcome research to substantiate the efficacy of interventions other than those reported in this study, Roth and Fonagy implied that education concerning sleep, sleep clinics, and the reevaluation of sleeping medication that is repeatedly prescribed might be helpful when working with older adults experiencing sleep impairment.
A more recent study compared the use of cognitive-behavioral interventions, relaxation therapy, and a behavioral placebo intervention with 75 adults, ages 40 to 80 years, who experienced chronic primary insomnia (Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001). Cognitive-behavioral interventions included sleep education, stimulus control, and restrictions on time in bed. The relaxation intervention focused on progressive muscle relaxation, and the placebo intervention was a quasi-desensitization treatment. At the 6-month follow-up, the cognitive-behavioral intervention group showed greater improvements in the majority of the outcome measures than did the behavioral and placebo intervention groups. Although the mean age of the participants was relatively young (55.3 years), the results of this study indicate that cognitive-behavioral interventions can be useful for some older adults who experience chronic primary insomnia.
Dementias. The most common cause of dementia in later life is Alzheimer's disease, which affects 4 million persons at present and increases in incidence each decade after age 60 (Alzheimer's Disease Education & Referral Center, 2000). Despite considerable medical research, there remains no known cause of or cure for this disease, and treatment is limited to pharmacological interventions that slow its progress rather than provide a cure. The brain of the Alzheimer's patient is affected in a progressive manner, resulting in total disability and eventual death. The course of the disease may take as long as 12 to 20 years, during which time the family members become the focus of treatment interventions to assist them in coping with caregiver burden (Smyer & Quails, 1999).
Roth and Fonagy (1996) acknowledged numerous difficulties in developing empirical research on outcomes in dementia mental health treatment. For example, it is difficult to obtain control groups for such research, and without a control group, stability of function and slowing of decline are difficult to discern. In addition, the success of interventions varies depending on the stage of the dementia. Instead of limiting the information they provided concerning dementia treatments to empirical outcome research, Roth and Fonagy provided a brief synopsis of the types of research available (or not available) for the following common interventions used with dementia patients: special design of the care environment, reality orientation, reminiscence, validation therapy, psychotherapy, cognitive-behavioral therapy, and behavior modification.
Reality orientation is the most extensively evaluated psychological approach to treating dementia and is used exclusively in long-term care settings (Roth & Fonagy, 1996). Holden and Woods (1995) reviewed 21 controlled trials that indicated that reality orientation had a small but significant effect on measures of verbal orientation. This effect was in comparison to control groups or unstructured social groups. A few limited studies indicated effectiveness of 24-hour reality orientation in the areas of finding one's way around the ward or home, spatial orientation, cognitive abilities, and behavior. A recent meta-analysis of the reality orientation literature compared the results from six randomized controlled trials (Spector, Davies, Woods, & Orrell, 2000). All studies that were analyzed had significant results in favor of treatment, but none of the studies provided follow-up data. Significant results were found in the areas of cognitive abilities, memory, and information/orientation.
The results of studies of reminiscence, validation, and similar therapies are essentially the same as the results reported here for reality orientation. These approaches are typically used in inpatient settings and have an effect on cognitive abilities and daily functioning. Unfortunately, the literature is lacking in studies of interventions for older persons with dementia who are living in the community. Most such studies provide treatment for caregivers in an attempt to reduce caregiver burden (e.g., Connell, Janevic, & Gallant, 2001). The older adult experiencing dementia has traditionally been seen as a recipient of respite care rather than as a client for mental health practice; however, recently an argument has been made that the impaired older adult should be represented in research as well as interventions in order to address the myriad of cognitive, behavioral, and emotional concomitants of dementia (Woods, 2001).
Substance abuse. Substance abuse among older adults is a significant but hidden and underreported phenomenon (Myers, Dice, & Dew, 2000). Blow (1998) noted that as many as 17% of older adults may misuse or abuse prescription drugs or alcohol. Accurate assessment is difficult and complicated by comorbidity of dementia and other mental as well as physical disorders, including sleep disorders (Smyer & Quails, 1999). Although treatment outcomes tend to be less successful in age-heterogeneous groups, Holian (2000) found that older adults (over age 55 years) who abuse substances could be treated effectively in age-specific groups that emphasized the provision of social support and avoidance of confrontation. Holian noted that modifying treatment to meet the needs of older clients was essential to success.
Blow (1998) coordinated a large-scale meta-analysis of research on alcohol and substance abuse in later life, under the auspices of the Substance Abuse and Mental Health Services Administration (SAMHSA). A national panel of experts was convened to provide treatment recommendations based on cross-disciplinary research that included cognitive-behavioral and group approaches, individual counseling, marital and family therapy, and case management. A major conclusion of this panel was that persons who begin drinking heavily later in life, who presumably began drinking due to stressful life circumstances and losses, have more positive treatment outcomes than do persons who began drinking at an earlier point in life, who have well established patterns of alcohol abuse. At the same time, Blow also noted that research is lacking on gender and ethnic variation, the effects of aging on the course of alcohol abuse and treatment, problems and differential treatment strategies for persons who abuse alcohol earlier and later in life, prevention of abuse, and relapse prevention. Furthermore, he underscored the need for research on stress, coping, adaptation, and the relationship of these factors to substance abuse. Although counselors were included in the membership of the SAMHSA review panel, none of the studies examined in this project were conducted or reported in the literature by professional counselors.
Reflection Exercise #12