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COGNITIVE-BEHAVIORAL THERAPY

Cognitive-behavioral therapy (CBT) is a combination of cognitive and behavior therapies that are directive, time-limited, structured, and place great emphasis on homework exercises. While cognitive therapy emphasizes the role of cognitive processes in the origin and maintenance of psychological disorders, behavior therapy focuses on principles of learning theory and the role of reduced reinforcement in the creation and maintenance of these disorders. In cognitive therapy, individuals learn to identify and monitor distorted, negative thinking, to become aware of the relationship between such thoughts and negative assumptions about oneself—and of the association between thoughts and feelings. Individuals also learn to apply techniques to challenge these thoughts. In behavior therapy, individuals are taught to track the frequency of targeted behaviors and to understand the relationship between these behaviors and their antecedents and consequences. Furthermore, individuals learn techniques to increase or decrease particular events, and are taught skills such as problem solving, relaxation, and assertiveness. Both cognitive therapy and behavior therapy assume that psychological problems can be alleviated by teaching individuals new skills to identify negative thoughts, form adaptive thoughts, and alter maladaptive behavior patterns.

CBT is effective in treating the psychological problems of older adults. In a review of empirically validated psychological treatments for older adults (Gatz et al., 1998) reported that behavioral and environmental interventions can help older adults with dementia, sleep disorders, and depression.

Potential sources of change in psychotherapy with older adults

Potential modifications to psychotherapeutic regimens may be necessary due to the various changes inherent in the aging process as a result of development, cohort differences, and the social context of older adults. It is important to keep in mind that these changes represent hypotheses in need of empirical investigation. Outcomes of psychological interventions with older adults indicate that maturational changes with aging have no negative impact upon the use of CBT with older adults.

Development. Slowing in cognitive processes and memory changes may require changes in cognitive-behavioral therapy. For instance, therapeutic conversation may need to be slower and simpler with older clients. Furthermore, it may be necessary for therapists to repeat new material, to ask the client to summarize the information to make sure that he or she understands it, and to ask the client to take notes on important points to increase recall of information and the effectiveness of the therapeutic intervention.

Changes in therapy may also arise as a result of the more positive aspects of maturation. Older adults have many useful strengths and existing skills as a result of the stability of crystallized intelligence and the development of expertise in several life domains. Rediscovering these skills, rather than teaching new ones, may frequently occur in therapy. It is also important to note that the normal decline in fluid intelligence suggests that the therapist may need to guide the older adult to certain conclusions, rather than giving suggestions and expecting the client to infer them.

Emotional changes that come with maturity may also affect the presentation of problems, requiring an adjustment of cognitive interventions. Research on emotion suggests that young adults experience pure and intense emotions, whereas older adults experience both sad and happy emotions in response to the same environmental or cognitive stimulus. Instead of replacing a negative, distorted thought with a more neutral or positive thought, it may be more strategic to have the older client focus on both the positive and negative emotions experienced.

A tendency for older adults to reminisce may make it difficult to focus on the present in CBT. Keeping an exclusively present-oriented focus when working with older adults who want and need to talk about the past is likely to be counterproductive. It is important to allow time for reminiscence, which may be perceived as reinforcement for other therapeutic work.

Cohort differences. In working with older adults, it is important to be aware of cohort differences that may influence the process of therapy. Cohort differences refer to an individual's membership in a birth-year group and the socialization process that shapes the abilities, beliefs, attitudes, and personality aspects of individuals born in a specific cohort. The attributes of a cohort are believed to be stable as the cohort ages, and thus differentiate it from those born earlier and later. For example, later-born cohorts (people who are now younger) have more years of formal education, are superior in reasoning ability and spatial orientation, and are more extroverted. Consequently, it may be necessary to change the wording of scales or assignments to adjust to different education levels of earlier cohorts and to adapt to cohort-specific values or examples in order to increase comfort with written assignments given in CBT. Thus, younger therapists working with older adults need to learn what it was like to grow up before the therapist was born because cohort differences in education level, intellectual skills, and personality may influence the process of therapy.

Social environment. Knowledge of the social context of older adults is crucial for appropriate interventions within both classic behavioral and social learning models of therapy because reinforcement contingencies that create or maintain maladaptive behavior or negative affect often arise from the environmental context. Staff in nursing homes, for example, may reward older adults for passively conforming to scheduled routines, a passivity that may result in reduced activity levels, lowered sense of control, and worsened mood. In order to improve the client's mood, the environment will need to be changed or staff will need to be consulted about possible environmental changes in the client's highly structured residential setting.

Cognitive-behavioral interventions for late-life problems

Many older adults who seek help in therapy deal with problems that threaten their well-being, including chronic illness, disability, and the death of loved ones. These problems are not unique to late life, but they are likely to occur more frequently at older ages. Furthermore, the usual difficulties of life, such as disappointments in love, arguments with family, and failure to achieve goals, can also take place in late life. Finally, many persons who struggle with depression, anxiety, substance abuse, or psychosis in their younger years continue to do so in their later years.

Chronic illness and disability. Conducting CBT with distressed older adults often means working with a population that is chronically ill, physically disabled, or both, and that struggles to adjust to these problems. In working with this population, it is important to learn about chronic illnesses and their psychological impact, control of chronic pain, adherence to medical treatment, rehabilitation strategies, and assessment of behavioral signs of medication reactions.

A frequent element of treating chronically ill or disabled elders is addressing concurrent depression, since up to 59 percent of this population experiences depression. Although there have been few studies examining the effectiveness of cognitive-behavioral therapy with medically ill older adults, results are encouraging for both outpatient and inpatient populations. Rybarczyk et al. (1992) have identified five important issues in applying CBT to chronically ill older adults: (1) solving practical barriers impeding participation, (2) acknowledging that depression is a separate and reversible problem, (3) limiting excess disability, (4) counteracting the loss of important social roles and autonomy, and (5) challenging the thought of being a "burden." For instance, in challenging the belief of being a burden on a family caregiver, the therapist may help the client to recall things he or she has done for the family caregiver in the past, thereby providing the client with a greater sense of equity in the relationship. Breaking down the issues facing the chronically ill older adult is helpful to the therapist in developing a strategy using both cognitive-behavioral techniques and practical considerations.

In addition to treating depression in medically ill or disabled elders, cognitive and behavioral techniques are also effective in managing pain associated with rheumatoid arthritis and delayed healing from injuries. Cognitive pain-management methods include distracting oneself from the pain, reinterpreting pain sensations, using pleasant imagery, using calming self-statements, and increasing daily pleasurable activities.

Depression. As mentioned previously, depression is prevalent in older adults who are chronically ill, disabled, or grieving; although the prevalence of depression in older adults is less than in young adults. Cognitive and behavioral approaches are effective in relieving depression in older adults. In treating depression, CBT focuses on teaching new coping strategies to deal with problems and on challenging those thoughts that interfere with effective coping. The client's participation in daily events that affect mood may also be addressed in therapy. By using a chart to monitor the frequency of these events, the therapist enables the client to see the relationship between pleasant events and moods, so that the frequency of pleasant events can be increased while the frequency of unpleasant events is reduced during the course of therapy. The therapist may also use the dysfunctional-thought record, a technique showing self-talk and negative interpretation of events, to enable the client to recognize distorted thoughts and replace negative and irrational thoughts with more adaptive ones.

Anxiety. Anxiety is fairly common in late life, but it is an understudied problem. Results from various studies indicate that brief courses (less than twenty sessions) of cognitive-behavioral therapy may be effective in treating late-life anxiety. In cognitive therapy, distorted thoughts that may exacerbate anxiety, such as "My heart is beating faster, which means I am about to have a heart attack" are challenged (Wetherell, 1998). Other cognitive restructuring techniques consist of making more accurate risk estimates; "decatastrophizing" by determining ways to cope with the feared situation; stopping thoughts by noticing and eliminating anxiety-provoking thoughts; and replacing automatic, anxious thoughts with positive thoughts. Relaxation training is often combined with diaphragmatic breathing and cognitive restructuring. For a review of treatment of anxiety in older adults, see Wetherell (1998).

Alcohol abuse. Even though alcoholism rates are lower for older adults than for younger adults, older problem drinkers often drink in response to loneliness, depression, and poor social-support networks. Consequently, CBT for the treatment of alcoholism in older adults focuses on improving the client's life in various ways in addition to just abstaining from drinking. Studies indicate that CBT models are effective in treating alcoholism in older adults, although further research is needed because not all studies have included a control group.

Stopping drinking completely, or at least achieving a period of abstinence followed by very limited and controlled drinking is a mandatory goal in treatment. Analysis of the drinking behavior itself also takes place to figure out the maladaptive purpose underlying the drinking behavior. Coping skills and behavior alternatives are then developed and practiced in therapy to handle situations in which the urge to drink arises. Irrational thoughts associated with the drinking are also challenged during therapy to increase the mood and self-esteem of the client, which in turn helps to control drinking behavior.

Conclusion

CBT may be effectively adapted for use with older adults by applying minor modifications to clinical techniques, since the principles of cognitive and behavioral theory are assumed to be similar for older and younger adults. Deciding which modifications to make, and how to conduct them, relies on a complete understanding of the various changes inherent in the aging process as a result of development, cohort differences, and the social context of older adults. Applying CBT to older clients entails several challenges, including learning about the social environment of older adults, working with clients whose experiences may be different from and prior to those of the therapist, and dealing with the interplay of physical and psychological problems on a frequent basis. Those who take on the challenge are likely to discover that their ideas about therapy and about aging will be transformed by working with older clients.

BOB G. KNIGHT GIA S. ROBINSON

See also ALCOHOLISM; ANXIETY; BEHAVIOR MANAGEMENT, BEREAVEMENT, DEPRESSION; GERIATRIC PSYCHIATRY; INTELLIGENCE; PSYCHOTHERAPY.

BIBLIOGRAPHY

AREAN, P., and MIRANDA, J. "The Treatment of Depression in Elderly Primary Care Patients: A Naturalistic Study." Journal of Clinical Geropsychology 2 (1996): 153–160.

BALTES, M. M. "Dependency in Old Age: Gains and Losses." Current Directions in Psychological Science 4 (1995) 14–18.

CARSTENSEN, L. L.; EDELSTEIN. B. A.; and DORNBRAND, L., eds. The Practical Handbook of Clinical Gerontology. Thousand Oaks, Calif.: Sage Publications, 1996.

COOK, A. J. "Cognitive-Behavioral Pain Management for Elderly Nursing Home Residents." Journal of Gerontology: Psychological Sciences 53B (1998): P51–P59.

DUFFY, M. Handbook of Counseling and Psychotherapy with Older Adults. New York: John Wiley, 1999.

FINCH, E.; RAMSAY, R.; and KATONA, C. "Depression and Physical Illness in the Elderly." Clinics in Geriatric Medicine 8 (1992): 275–287.

GALLAGHER-THOMPSON, D., and THOMPSON, L. W. "Applying Cognitive-Behavioral Therapy to the Psychological Problems of Later Life." In A Guide to Psychotherapy and Aging. Edited by S. Zaret and B. G. Knight. Washington, D.C.: American Psychological Association, 1996: Pages 61–82.

GATZ, M.; FISKE, A.; FOX, L. S.; KASKIE, B.; KASL-GODLEY, J.; MCCALLUM, T.; and WETHERELL, J. "Empirically-Validated Psychological Treatments for Older Adults." Journal of Mental Health and Aging 4 (1998): 9–46.

KNIGHT, B. G. Psychotherapy with Older Adults, 2d ed. Thousand Oaks, Calif.: Sage Publications, 1996.

KNIGHT, B. G., and SATRE, D. D. "Cognitive-Behavioral Psychotherapy with Older Adults." Clinical Psychology: Science and Practice 6 (1999): 188–203.

LICHTENBERG, P. A. A Guide to Psychological Practice in Geriatric Long-Term Care. New York: Haworth Press, 1994.

LOPEZ, M. A., and MERMELSTEIN, R. J. "A Cognitive-Behavioral Program to Improve Geriatric Rehabilitation Outcome." The Gerontologist 35 (1995): 696–700.

RYBARCZYK, B.; GALLAGHER-THOMPSON, D.; RODMAN, J.; ZEISS, A.; GANTZ, F. E.; and YESAVAGE, J. "Applying Cognitive-Behavioral Psychotherapy to the Chronically Ill Elderly: Treatment Issues and Case Illustration." International Psychogeriatrics 4 (1992): 127–140.

SCHONFELD, L., and DUPREE, L. W. "Treatment Approaches for Older Problem Drinkers." The International Journal of the Addictions 30 (1995): 1819–1842.

TERI, L.; CURTIS, J.; GALLAGHER-THOMPSON, D.; and THOMPSON, L. W. "Cognitive-Behavior Therapy with Depressed Older Adults." In Diagnosis and Treatment of Depression in Late Life. Edited by L. S. Schneider, C. F. Reynolds, B. Liebowitz, and A. J. Friedhoff. Washington, D.C.: American Psychiatric Press, 1994. Pages 279–292.

WETHERELL, J. L. "Treatment of Anxiety in Older Adults." Psychotherapy 35 (1998): 444–458.

WIDNER, S., and ZEICHNER, A. "Psychological Interventions for the Elderly Chronic Pain Patient." Clinical Gerontologist 13 (1993): 3–18.

ZARIT, S. H., and KNIGHT, B. G., eds. A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage Context. Washington, D.C.: American Psychological Association, 1996.

ZEISS, A. M., and STEFFEN, A. "Behavioral and Cognitive-Behavioral Treatments: An Overview of Social Learning." In A Guide to Psychotherapy and Aging. Edited by S. Zarit and B. G. Knight. Washington, D.C.: American Psychological Association, 1996. Pages 35–60.