Psychotherapy with Older Adults
Publication Year: 2004
This Third Edition of the bestselling Psychotherapy with Older Adults continues to offer students and professionals a thorough overview of psychotherapy with older adults. Using the contextual, cohort-based, maturity, specific challenge (CCMSC) model, it draws upon findings from scientific gerontology and life-span developmental psychology to describe how psychotherapy needs to be adapted for work with older adults, as well as when it is similar to therapeutic work with younger adults. Sensitively linking both research and experience, author Bob G. Knight provides a practical account of the knowledge, technique, and skills necessary to work with older adults in a therapeutic relationship. This volume considers the essentials of gerontology as well as the nature of therapy in depth, focusing on special content areas and common themes.
- Front Matter
- Back Matter
- Subject Index
- Chapter 1: Gerontology for Psychotherapists: The Contextual, Cohort-Based, Maturity, Specific-Challenge Model
- Case Study
- Why Did This Happen?
- Combating Misconceptions about Older Adults
- The Contextual, Cohort-Based, Maturity, Specific-Challenge Model
- Microlevel Cognitive Changes with Aging
- Learning and Memory
- Personality and Emotional Development
- Summary: Evidence of Increasing Maturity Through Adulthood
- Cohort Differences
- The Social Context of Older Adults
- The Specificity of Challenges in Late Life
- Chronic Illness and Disability
- Specific Challenges Summary
- Chapter 2: Adaptations of Psychotherapy for Older Adults
- Adapting Psychotherapy for Work with Older Clients
- Adaptations Due to Development and Maturation
- Fluid versus Crystallized Intelligence
- Expertise and Greater Cognitive Complexity
- Emotional Changes in Later Life
- Personality Change and Stability across Adulthood and into Old Age
- Cohort-Based Adaptations
- Adaptations Based on the Social Context of Older Adults
- Residential Settings as Examples of Contexts
- Active Assistance for the Older Client
- Summary: A Framework for Optimism
- Chapter 3: Building Rapport with the Older Client
- The Decision to Seek Therapy
- Educating Clients about Therapy
- Establishing Rapport with the Older Client
- Developmental Influences
- Cohort Influences
- Social Context Influences
- Age-Graded Social Roles
- Illness- or Disability-Related Influences
- Home Visits and Rapport Building
- Professional Competence and the Age Difference Issue
- Chapter 4: Transference and Countertransference with Older Clients
- Therapists' Responses to Work with Older Clients
- The Therapist as the Client's Child
- The Therapist as Grandchild
- The Therapist as Parent
- The Therapist as Spouse at an Earlier Age
- Erotic Transference
- The Therapist as Authority Figure or Magical Expert
- Issues with the Institutionalized Elderly
- Parental Countertransference
- Grandparent Countertransference
- Therapists' Fears of Aging, Dependency, and Death
- Countertransference and Placement Decisions
- Teaching Transference and Countertransference
- Chapter 5: Guidelines for Assessment in the Context of the Practice of Psychotherapy
- Base Rates of Presenting Problems
- Deciding among Domains of Intervention
- Deciding among Psychological Disorders
- Choosing Interventions
- Values Placed on Choices Based on Assessments
- Chapter 6: Grief Work with Older Adults
- Is Depression during Bereavement Normal?
- Clinical Grief Work
- The Expression of Emotion
- Putting the Loss in Perspective
- Designing a New Life
- Some Observations on Grief Work as a Process
- Therapist-Centered Issues in Grief Work
- Is Grief Work a Model for All Therapy with the Elderly?
- Chapter 7: Chronic Illness in Later Life
- Emotional Consequences of Illness and Disability
- Understanding Illness and its Consequences
- Between a Rock and a Hard Place: How Much Independent Behavior is Healthy?
- Accurate Attribution of Experienced Symptoms
- Techniques for Working with Older Chronically Ill Clients
- The Role of Relaxation Training
- Pleasant Events Approaches for Improving Emotion after Illness and Disability
- Cognitive Restructuring
- Contingency Analysis and Psychological Intervention in Illness and Treatment
- Recognizing and Naming Emotions
- Issues for the Therapist Working with Chronically Ill Older Adults
- Knowledge about Physical Illness and Medical Treatment
- Communicating with Physicians
- Understanding Medical Settings and the Patient's Point of View
- The Therapist's Reaction to Physical Illness
- Chapter 8: Psychotherapy and the Person with Dementia
- Therapy during Early-Stage Dementia
- Psychological Interventions during the Middle Stages of Dementia
- Talking Therapy: Emotion-Oriented Interventions
- Cognitive Retraining in the Person with Dementia
- Behavioral Interventions
- Psychology and End-Stage Dementia Care
- Chapter 9: Psychotherapy with Family Caregivers of Frail Older Adults
- Stress and Coping Model
- Family Systems and Caregiving
- Cognitive Behavioral Interventions for Caregivers
- Relaxation Training
- Scheduling Relaxing Events
- Cognitive Reframing
- Support Groups for Caregivers
- Psychotherapy with Caregivers
- Family Sessions and Caregiving
- Chapter 10: Life Review in Psychotherapy with Older Adults
- The Role of Life Review
- Erikson and Developmental Stages
- The Life Course Perspective in Gerontology
- Revisionist Reflections on Dr. Borg's Life Cycle
- Strategic Issues for the Therapist Guiding a Life Review
- When to Review the Client's Life
- A Complete Life History
- The Therapist as Editor
- The Future: Life after Life Review
- Chapter 11: Ethical Issues and Concluding Thoughts on Psychotherapy with Older Adults
- Ethical Issues with Older Clients
- Beneficence versus Autonomy
- Concluding Thoughts on Psychotherapy with Older Adults
- Toward an Integrative Therapy with Older Adults
Copyright © 2004 by Sage Publications, Inc.
All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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Library of Congress Cataloging-in-Publication Data
Psychotherapy with older adults / by Bob G. Knight.— 3rd ed.
Includes bibliographical references and index.
ISBN 0-7619-2372-1 (cloth : alk. paper)—ISBN 0-7619-2373-X
(paper : alk. paper)
1. Psychotherapy for the aged. 2. Aged—Mental health. I. Title.
Printed on acid-free paper in the United States of America.
04 05 06 07 08 09 10 9 8 7 6 5 4 3 2 1
Acquiring Editor: Jim Brace-Thompson
Editorial Assistant: Karen Ehrmann
Project Editor: Claudia A. Hoffman
Copy Editor: Catherine M. Chilton
Typesetter: C&M Digitals (P) Ltd.
Indexer: Molly Hall
Cover Designer: Michelle Lee Kenny
Jim Brace-Thompson, my editor at Sage Publications, initiated the idea that it was time to begin working on a third edition of this volume. He has been patient and supportive throughout the process, particularly during delays imposed by other professional demands, including grant administration and my becoming Director of Clinical Training in the University of Southern California Psychology Department. It is a running theme in our conversations that an oddity of our professional lives is that we typically meet at conventions all over the United States and Canada, even though we live in neighboring towns in Southern California. Claudia Hoffman and Catherine Chilton guided the book through the postproduction and copyediting phases with considerable skill, patience, and grace.
The intellectual and professional influences on me have multiplied and grown so much over the years that any listing is sure to be incomplete and therefore to delete some who should have been included. Margaret Gatz is a long-term colleague and has continued to influence my thinking about psychotherapy with older adults, especially when we coteach the course on that topic at USC. My students and clinical supervisees at USC constantly teach me as they learn from me. Sara Qualls of the University of Colorado at Colorado Springs, in many conversations at conventions, has stimulated my thinking about doing and teaching psychotherapy. Michael Duffy of Texas A&M has challenged me often to examine in new ways what I have said and written, and he was a key influence on my decision to include the chapter on psychotherapy with persons with dementia. David Powers and Lynn Snow also provided encouragement and inspiration for the chapter on dementia.
Several British geropsychologists have become strong influences on my thinking about this book and about psychotherapy with older adults, including Murna Downs, Mary Gilhooly, Fiona Goudie, Ken Laidlaw, and Bob Woods. Carolien Lammers helped to frame for me the distinction [Page xii]between approaches to psychotherapy rooted in life span developmental psychology and its concern with normal aging and those approaches that are more purely clinical and therefore rooted in the psychopathology of aging. This distinction highlights differences between national approaches to the topic as well as differences between training models within nations.
Lucio Bizzini at the University of Geneva Hospitals challenged me to think more about the distinction between healthy aging and frailty in later life and influenced changes in this edition. Inger Hilde Nordhus and her colleagues at the University of Bergen (Norway) were among the first to encourage me to think beyond the boundaries of the United States with regard to psychotherapy and aging, and they also provide a good model for theoretical integration of psychodynamic and cognitive behavioral approaches with older adults.
And, of course, thanks to all of the older adults who shared their lives with me or with the trainees that I've supervised (and so with me via recording of their therapy sessions). Their active participation in, and resistance to, the therapeutic process is the foundation upon which this book rests.
The knowledge base for psychotherapy with older adults continues to grow and to refine the image of later life that can inform and guide clinical work with older adults. Since the second edition of this book went to press in 1995, a number of books and handbooks related to this topic have appeared, and the pace of research both in clinical geropsychology and in the basic science of life span developmental psychology has increased. One goal of this revised edition is to incorporate these new findings, both in updating information and in revising the contextual, cohort-based, maturity, specific-challenge (CCMSC) model in some respects.
There are two new chapters in this volume. In several conversations with other clinical geropsychologists since the second edition appeared, I have been asked why I have not addressed working with clients who have dementing illnesses. When Sage asked me to work on this revision, the reviewers that they contacted also mentioned the lack of coverage of psychotherapy with persons with dementia in earlier editions. It is one marker of the changing attitudes toward psychological interventions with persons with dementia that this would be a consensus request at present. A chapter on working with persons at various levels of cognitive impairment appears in this edition.
The second chapter also covers an omission that occurred to me shortly after the publication of the second edition. Although I have been professionally involved in services to caregivers since 1980, helped to organize one chapter of the Alzheimer's Association, and have been faculty director of the Los Angeles Caregiver Resource Center since 1989, the earlier editions of this book have not specifically covered psychological interventions with caregivers of the frail elderly. Clearly, caregiving is one of the specific challenges of later life and so deserves the new chapter devoted to it in this volume.
Another change in this volume is the incorporation of some of the case material from Older Adults in Psychotherapy (Sage, 1992). The integration [Page xiv]of these case examples in abbreviated form into the discussion of psychotherapy is intended to enrich and provide concrete examples of the points covered in this discussion of changes in psychotherapy when working with older adults.
As with the previous editions, this volume continues to draw upon findings in life span developmental psychology and in scientific gerontology to explore how psychotherapy needs to be adapted for work with older adults. In general, the answers to this question are rooted more in differences among cohorts born at different points in time, in differences between the social contexts of older and younger adults in our society, and in the distinctive challenges of later life rather than in aging as a developmental process.
This distinction between aging itself and other influences on older adults' thinking and behavior is sometimes salient and sometimes subtle, but it is always important in the accurate understanding of what it means to be an older person. As is explored in this volume, the distinction is important for both therapist and client.
Working with older adults is a challenging and often touching experience. The problems faced by older clients often cut across the typical boundaries between medicine, psychology, and social services. Working with members of earlier born cohorts expands our awareness of human diversity and of the scope of societal change over successive decades. Working within the sometimes distinctive social contexts of older adults teaches us what we as a society do to the elderly as well as for them. For myself, the field of psychotherapy with older adults has been rewarding both intrinsically and extrinsically I hope you find it so as well.—
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About the Author[Page 289]
Bob G. Knight, Ph.D., is the Merle H. Bensinger Professor of Gerontology, Psychology, and Counseling Psychology at the University of Southern California. At USC's Andrus Gerontology Center, he serves as Director of the Tingstad Older Adult Counseling Center and Faculty Director of the Los Angeles Caregiver Resource Center; in the Department of Psychology, he is Director of Clinical Training (2002). His research interests include caregiving, emotion and aging, and mental health policy and aging, and he has published extensively in mental health and aging, including Outreach with the Elderly (1989) and Older Adults in Psychotherapy: Case Histories (Sage, 1992). He is Senior Editor of Mental Health Services for Older Adults: Implications for Training and Practice in Geropsychology (1995) and a coeditor of A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage Context (1996). He has been active in various professional organizations relating to psychology and aging: He served as President of Section II, Division 12 (Clinical Geropsychology) of the American Psychological Association in 1997 and as President (2003–2004) of APA Division 20 (Adult Development and Aging), as well as Chair of the APA Committee on Aging in 2001. He received his Ph.D. in clinical psychology from Indiana University, Bloomington. His professional experience in working with older adults began while he was working at the Urban League of Madison County (Indiana), where he organized and served as first President of the Madison County Council on Aging in 1973.