Psychoeducation and the Early Phases of CT with Older Adults

The initial phases of CT typically focus on first ascertaining the patient's reasons for seeking treatment, his/her experience with therapy and expectations, then socializing the patient to CT. Older adults in particular may need considerable education about the expectations of therapy, as well as the structure of CT. Often, older adults' attitudes about their own age group can interfere with effective treatment (Knight, 2004; Laidlaw et al., 2003). Older people often have little exposure to psychotherapy compared to younger adults; thus, they may require information regarding what mental health services are and how therapy is distinct from needing inpatient care or having severe mental illness (being "crazy"), and to learn that although depression is often a common reaction to grief, loss, and transition in social role, it can be treated in late-life. Laidlaw, Thompson, and Gallagher-Thompson (2004) suggest that therapists can encourage attitu-dinal change by acknowledging that although members of the individual's cohort may share these beliefs, these beliefs are no longer prevalent in today's society given advances in our knowledge about mental health and illness.

In addition to educating older patients about depression and CT, therapists also need to determine any limitations to coming to therapy on a regular basis. For instance, older patients commonly have limited resources with regard to travel and rely on others to get to appointments (Coon & Gallagher-Thompson, 2002). Furthermore, some older patients still work or take care of family members, and have little time for homework, reading new material, or coming to weekly appointments. Some older patients are too disabled to attend regularly, or they may become disabled during the course of treatment and no longer be able to attend as expected. Therapists working with older patients need to remain flexible with regard to the therapeutic frame; by determining these potential limitations early on in treatment; they can prevent problems in starting the therapy process. Some therapists provide initial case management services to link older patients to services that facilitate the use of therapy, such as senior transportation or respite care (Coon & Gallagher-Thompson, 2002). Others arrange to provide home-based therapy, or therapy in a setting that is more convenient for the older patient to access, such as a senior center or a church (Arean et al., 2005; Scogin et al., 2003). Although preliminary, there is also recent evi dence to suggest that telephone-based CT is not only effective in treating depression in disabled patients, but results in near perfect attendance and adherence (Mohr, Burke, Beckner, & Merluzzi, 2005).

To illustrate the importance of flexibility in the therapeutic frame, we turn to Mr. Z, who was considerably disabled by his poorly fitting prosthesis and at one point developed a pressure sore that became infected. Because could not leave his house easily, Mr. Z had indicated to the therapist that he would be unable to resume therapy until his leg healed and he was fitted for a new prosthesis. The therapist offered to come to Mr. Z's home while he was healing, which Mr. Z appreciated. This flexibility allowed Mr. Z to continue treatment and make gains despite a setback in his health. Had the therapist simply agreed to meet again when Mr. Z had healed, they would have had a six-week interruption in treatment.

In these initial sessions, therapists also need to attend to any sensory deficits older patients may have. At least 14% of noninstitutionalized older adults have some type of sensory deficit; 35% of older adults age 85 and older have these impairments (Waldrop & Stern, 2003). When conducting therapy with an older adult with visual or hearing problems, the therapist should sit in front of the person in a well-lighted environment when speaking. Although many therapists prefer muted lighting in their offices to instill a calming effect, this may impair an older person's ability to connect to the therapist. Therapists should encourage visually impaired patients to use devices such as magnifying glasses and large-print materials. A therapist may want to consider utilizing other modalities to present therapy modules, such as audiotaping sessions and providing auditory instructions for homework and data collection (e.g., audiotaped thought diaries). Similarly, when conducting therapy with an older adult with a hearing impairment, it is important to use amplifying technology if possible. If the person wears a hearing aid, ensure that it is turned on or working correctly. Even with advances in hearing aid technology, it is often surprising how many older people either do not know how to, or do not want to use these aids. We require new clinicians at the Over-60 Clinic program to attend free workshops offered by the Light House and the Center on Deafness to understand better how reading and listening aids work. During sessions, therapists often use gestures or objects to assist with communication (Springhouse, 2001), or bibliotherapy to support the information being taught in session (Coon & Gallagher-Thompson, 2002). Finally, therapists should consider using short sentences, taking care to enunciate words (National Institute on Aging, 2002). These strategies should assist in promoting better communication, therefore facilitating the therapy process.

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